Every finding on record at Edison Christian Health Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 9/15/25 at 9:32 AM, An interview with Production Manager (PM) SS found that staff check dates of food products daily. Further review of the walk-in cooler found an open package of roast beef with no date, a container of cut pineapple with no date, pumpkin dated 8/25 to 8/31, a bag of kielbasa sausages open with no date, and a container of scrambled eggs uncovered and not dated. On 9/15/25 at 9:38 AM, Observation of the two door Traulsen cooler found a container of leaf lettuce dated 9/6 to 9/9. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On 9/15/25 at 9:37 AM, Observation of the walk-in cooler found a covered container of mechanical breakfast sausage. At this time visual humidity was found forming on the inside of the saran wrap cover. The surveyor took a temperature of the sausage at this time and found it to be 130F. When asked about the mechanical sausage, PM SS stated that it was made this morning for breakfast and that he need to finish cooling. The item was not on the cooling log at this time. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. On 9/15/2025 at 9:43AM, Observation of a pan of cooked beef patties at 106 degrees, stored on the grill. During interview with [NAME] AA it was stated that the cooking temperature of the patties was 165F before being placed in the pan with liquid beef base. On 9/15/2025 at 10:37AM, Observation in the [NAME] Hall dining room, there were three breakfast trays stored in the warming unit that was registering 116 degrees on the digital temperature gauge. Food Service Manager (FSM) E took the temperature of a food item on one of the food trays with a rapid read thermometer and stated food was at 116 degrees. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. P On 9/15/25 at 9:49 AM, Observation of the can opener on the preparation table found heavy black accumulation on the blade, bar, and the inner mechanism of the opener. An interview with PM SS found that it should get cleaned weekly. On 9/15/25 at 9:52 AM, Observation of the cook line found the kitchen microwave with an accumulation of dried food debris. When asked about the condition of the microwave, [NAME] AA stated that it needs to be cleaned. On 9/15/2025 at 10:29AM, Observation of Kitchen prep area found dried food debris stuck on the mixing guard and on the neck of the stand mixer. When asked PM SS stated the stand mixer was not used that morning and was unsure when the mixer was last used. On 9/15/25 at 10:37 AM, observation of the [NAME] Dining room, the ice machine was found with black accumulation on the ice spout. Interview with FSM E found that Maintenance takes care of the ice machine cleanings and staff wipe down the unit. On 9/15/25 at 10:45 AM, Observation of the Front Dining Room found the Coffee and Juice machines with accumulations of dark spotted debris on non-food contact surfaces between the spouts. On 9/15/25 at 11:06 AM, Observation of the [NAME] Dining room found the Ice machine spout with brown and white crusted debris. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

DPS #1 Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting residents in the following areas:Findings include: DPS #2 Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in 1 (Resident #18) of 19 residents reviewed for a clean, homelike environment, resulting in a build of up dust and debris on surfaces in the resident's room and the potential for decreased satisfaction with the living environment.Findings include: On 9/15/25 at 10:24 AM, Observation of the Main dining room found the cabinet underneath the ice machine with an accumulation of black staining and debris. On 9/15/25 at 10:38 AM, Observation of the [NAME] dining room found trash bags stored underneath the sink, with the cabinet having a large hole in the back where plumbing comes from the wall. Further review found a heavy accumulation of black debris on the bottom and back side of the cabinet. On 9/15/25 at 10:37 AM, Observation of the Front kitchenette found a large hole underneath the sink cabinet where plumbing comes from the wall. On 9/15/25 at 2:58 PM, Observation of the Clean utility room on the South Hall found briefs and gloves stored on the floor. On 9/15/2025 at 3:30PM, Observation in the [NAME] dining room, there was a large accumulation of liquid pooling under the ice machine, and beverage dispenser. The liquid was also leaking down the cabinet and soaking into the carpet underneath. The Maintenance Director P was unaware of the pooling liquid and unsure where the liquid was coming from. On 9/15/25 at 3:31 PM, Observation of the Clean Linen room found an excess of dust, debris, and items behind the wheeled cart used for storage of linen. On 9/15/25 at 3:37 PM, Observation of the [NAME] bath found shampoo, body wash, toilet paper, and disinfectant comingling in the cabinet. On 9/15/2025, 3:38PM Observation of a shower curtain, in the [NAME] bath, with mildew in the creases at bottom of curtain. On 9/16/2025 at 8:40AM, Interview with Purchasing Manager PM EE, regarding housekeeping operations, it was stated showers were cleaned and disinfected during the daily cleaning by housekeeping and that Head Nurses would also report observations if additional cleaning was needed. On 9/15/25 at 3:40 PM, Observation of the [NAME] Housekeeping closet found the faucet connected to a chemical pre-dispense with no way to relieve the backpressure the system puts on the faucets internal vacuum breaker. Maintenance Director P stated he would add a wasting tee to the faucet. On 9/15/25 at 3:42 PM, Observation of the [NAME] Soiled utility room found that the over hopper faucet was not able to be turned on, indicating a stagnant line. Further review of the room found that the ventilation exhaust was not heard or visually observed with suction. MD stated that it usually has good suction when working. DPS #1 findings continued: During an observation on 9/15/25 at 9:24am, a large pink stain, approximately 18 inches x 3 feet, was noted on the carpet, to the right of the door, in the dining room of the [NAME] Hall. Between table 2 and 3, along the exterior wall of the dining room, a section of carpet approximately 12x12, was soiled with a white substance that appeared to be dried food. Residents sat nearby, eating breakfast. Nursing staff were observed in the dining area, assisting residents. During an observation on 9/16/25 at 9:52am, the position of some of the tables in the dining area had been rearranged. A large pink stain, approximately 18x3 was noted under a resident dining table, to the right of the door, in the dining room of the [NAME] Hall. An unknown female resident sat at table 2, which had been moved, and now sat directly over a white dried substance that appeared to be dried food. The soiled section of carpet was directly under the resident's feet. In an interview on 9/17/25 at 10:20am, Certified Nursing Assistant (CNA) DD reported staff were expected to report a need for carpet cleaning to Environmental Services (EVS). In an interview on 9/17/25 at 10:46am, Licensed Practical Nurse (LPN) CCC reported nursing staff were expected to report soiled carpet issues to EVS via the computerized communication system. When further queried, LPN CCC reported EVS generally cleaned the carpet within 24 hours of notification. In an interview on 9/17/25 at 11:19am, Environmental Service Supervisor (ESS) XX reported until very recently, the facility did not have a carpet cleaning schedule and did not maintain an ongoing record of carpet cleaning for the dining area of the [NAME] Hall. ESS XX reported the expectation was that the carpet was cleaned at least every other week and as needed when spills occurred. ESS XX reported housekeeping staff/floor care staff were expected to inspect the cleanliness of the carpet in the [NAME] Hall dining room daily and immediately report any cleaning needs. ESS XX reported nursing staff were also expected to report carpet cleaning needs because residents in that area frequently spilled food/drinks/had uncontained incontinence. When further queried, ESS XXX reported he was unaware of the soiled carpet in the [NAME] Hall dining room until it was reported as a concern by a surveyor. Findings DPS #2: Resident #18 Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (cognitive decline caused by damage to the blood vessels of the brain), chronic bronchitis (chronic lung condition characterized by persistent inflammation of the airways, leading to excessive mucus production and persistent cough). Review of a Minimum Data Set (MDS) assessment for Resident #18 with a reference date of 8/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #18 could not complete the assessment. Section O of the MDS revealed Resident #18 was on oxygen therapy. During an observation on 9/15/25 at 9:50am, Resident #18 slept in her bed with an activated, free-standing fan positioned approximately 2 feet from the bed. The height of the fan caused it to blow air directly toward the resident's face. Several dime sized areas of dust and debris were noted on the metal fan guards, both in front of and behind the fan blades. The motor casing of the fan was dust covered, and the base was soiled with dried liquid, dust and debris. A collection of dust and debris was noted on the floor behind Resident #18's oxygen concentrator. During an observation on 9/16/25 at 10:17am, Resident #18 slept in her bed. The free-standing fan was on, blowing air toward the resident's face. Dust and debris remained on the wire fan guards, on the casing around the motor and on the base of the fan. A collection of dust and debris was noted on the floor behind Resident #18's oxygen concentrator. During an observation on 9/17/25 at 10:39am, Resident #18 slept in her bed. The free-standing fan was on, turned toward the resident at face level, approximately 3 feet from the resident's bed. The dust and debris noted on the fan on 9/15/25 and 9/16/25, remained in place. A collection of dust and debris remained on the floor behind Resident #18's oxygen concentrator. In an interview on 9/17/25 at 10:43am, HSK K reported she cleaned Resident #18's room regularly. HSK K reported each resident's room should be cleaned daily and deep cleaned at least weekly. HSK K reported daily cleaning included sweeping and mopping the floor. HSK K reported she was not sure if housekeepers were expected to clean fans that were in a resident's room but she usually tried to clean them. In an interview on 9/17/25 at 11:19am, Environmental Services Supervisor (ESS) XX reported it was the responsibility of the housekeeper to ensure personal fans in resident rooms were kept clean. ESS XX reported the housekeepers were expected to use a vacuum cleaner to remove dust and debris from the surfaces of resident fans. Review of a Safe and Homelike Environment Policy with a reference date of 2025, revealed In accordance with residents' rights, the facility will provide a.clean, comfortable and homelike environment.3. Housekeeping and maintenance services will be provided as necessary.

Based on observation, interview, and record review the facility failed to implement an person-centered care plans in 1 (Resident #57) of 19 residents reviewed for care planning, resulting in the potential for unmet care needs. Findings include: Resident #57 Review of an admission Record revealed Resident # 57 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing food or liquids) and mild intellectual disabilities. Review of Resident #57's Care Plan revealed, (Resident #57) has potential for alteration in nutrition/hydration status r/t (related to) therapeutic diet, meds which may affect appetite/wt (weight) . hx (history) of swallowing issue at previous facility .spilling food d/t (due to) shaking hands. Date initiated: 1/20/25. Interventions: Diet as ordered: Consistent carbohydrate, regular texture, thin liquids. Small portions to promote weight loss and glycemic control. NO straws and weighted utensils. Date initiated: 1/20/25. Revision: 9/5/25. During an observation on 9/15/2025 at 12:51 PM, Resident #57 was sitting in her recliner in her room. Resident #57 had a cup of water with a straw sitting on her tray table. It was noted that there a sign on the wall behind Resident #57 dated 9/5/25 which stated, No straws. During an observation on 9/15/2025 at 3:45 PM, Resident #57 was sitting in her recliner in her room. It was noted that Resident #57 had two water cups sitting on her tray table with straws in both cups. During an observation on 9/16/2025 at 12:18 PM, Resident #57 was sitting in her recliner when Certified Nursing Assistant (CNA) G entered Resident #57's room and placed a water cup with a straw on her tray table and then exited Resident #57's room. Immediately after CNA G left Resident #57's room, CNA G entered Resident #57's room and delivered a cup of sprite with a straw to Resident #57. It was noted that Resident #57 was eating chicken noodle soup without weighted utensils. It was noted that Resident #57 was struggling to eat the soup with the spoon that she was using. In an interview on 9/16/2025 at 4:38 PM, Licensed Practical Nurse (LPN) BB reported that Resident #57 was supposed to use weighted utensils. LPN BB' reported that the staff did sometimes forget to bring weighted utensils when Resident #57 was eating in her room. LPN BB reported that she was not sure if Resident #57 was able to use straws with drinks. In an interview on 9/17/2025 at 9:41 AM, CNA ZZ reported that she was unsure if Resident #57 was able to use straws with drinks. CNA ZZ reported that the staff should follow the resident care plan to know if the resident required certain assistive devices with meals. CNA ZZ reviewed Resident #57's care plan with this writer and confirmed that Resident #57 was not supposed to have straws with drinks. In an interview on 9/17/2025 at 9:47 AM, Registered Nurse Supervisor (RN-S) AAA reported that Resident #57's care plan noted that she should have weighted utensils at all meals, and that she was not supposed to have straws with drinks. RN-S AAA reported the intervention to use weighted utensils and not give straws to Resident #57 with drinks was started on 9/5/25. RN-S AAA reported that when a resident had an update to their care plan, staff would print out two copies of the care plan, with the update highlighted and place it on the Care Plan book at the nurse's station and in the resident's room. RN-S AAA reported that staff were expected to review the care plan updates before providing care for residents in case there were changes. In an interview on 9/17/2025 at 9:25 AM, Therapy Manager (TM) BBB reported that Resident #57 had been receiving occupational therapy services since July 2025, and speech therapy services since August 2025. TM BBB reported that Resident #57 was receiving occupational therapy services due to decreased self-feeding. TM BBB confirmed that occupational therapy had ordered that Resident #57 use weighted utensils with all meals. TM BBB confirmed that Resident #57 had made improvements with self-feeding when using the weighted utensils. TM BBB reported that Resident #57 was receiving speech therapy services for difficulty swallowing. TM BBB confirmed that speech therapy had recommended that Resident #57 not use straws due to difficulty with swallowing. Review of the facility's Assistive Eating Devices policy last revised 1/2024 revealed, Policy: Assistive eating devices will be available for all residents needing support from improving independence and/or for resident safety. This includes meals, snacks, nourishments, and any time food or beverages are being served. Training and assistance will be provided to ensure that residents and/or staff understand and can use the assistive eating device . Review of the facility's Care Plan policy last revised 1/2025 revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Policy interpretation and implementation: 1 . The care plan identifies the highest level of functioning the resident may be expected to obtain; or maintain; or interventions appropriate for comfort when decline is the expected outcome . 3. Each resident's comprehensive person-centered care plan is centered and designed to: .e. reflects treatment goals, timetables, and objectives in measurable outcomes .g. aide in preventing or reducing declines in the resident's functional status and/or functional levels . h. enhances the optimal functioning of the resident by focusing on a rehabilitative program .

Based on interview and record review, the facility failed to prevent significant medication errors in 1 (Resident #65) of 5 residents reviewed for medication errors, resulting in Resident #65 receiving an unprescribed antiseizure medication and the potential for adverse side effects. Findings include: Resident #65 Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE] with pertinent diagnoses which included severe intellectual disabilities and chronic pain. Review of Resident #65's Progress Note dated 9/8/25 and documented by Licensed Practical Nurse (LPN) BB revealed, Due to med (medication error), full head to toe performed (assessment). Resident appears at baseline, other than drowsiness, denies pain when asked, responds yes when asked if sleepy. Vitals: BP (Blood pressure): 131/84, P (pulse): 78, O2 (oxygen saturation) 93 % RA (room air), RR (respiration rate): 16, T(temperature): 97.8. Resident ate 0-25% of lunch and did not drink well this shift. Would purse lips when approached. Will continue to push fluids. Checking vitals Q2H (every two hours). Resident responds appropriately to questions, rouses to voice . Review of Medication Error Form dated 9/8/25 revealed, .Medication/Dose/Route of administration involved: Clobazam 10 mg (benzodiazepine medication used to treat seizures) orally. Description of events: The incorrect narcotic was grabbed (roommate's). Given at 09:10 AM. Realized error at 3:00 PM when counting narcotics. 1. Medication error type: Wrong drug. 2. Failure to follow procedures (explain): Did not complete triple checks. Medication Error Classification: error occurred, resulted in need for increased monitoring, no harm. Corrective action: additional training. This form was signed by Director of Nursing (DON) B on 9/9/25 and Nursing Home Administrator (NHA) A on 9/9/25. In an interview on 9/16/2025 at 4:28 PM, LPN BB reported that the day that she had administered the wrong medication to Resident #65, the facility was short staffed, and she had more residents to care for than she typically would. LPN BB reported that she was going too fast during medication administration, and she had checked Resident #65's Medication Administration Record (MAR), then signed the narcotic count sheet for Resident #65's narcotic medication before she removed the narcotic medication from the locked cart. LPN BB confirmed that after she had documented the narcotic count of the medication, she grabbed Resident #65's roommates' narcotic medication and dispensed that medication instead of the medication that was ordered for Resident #65. LPN BB reported that she did not realize she had given Resident #65 the wrong medication until the end of her shift, when she was counting the narcotic medications with the oncoming nurse. LPN BB confirmed that she should have verified the narcotic medication when she was writing it down on the narcotic count sheet, and she should have also verified the medication again before she dispensed it. LPN BB confirmed that Resident #65 was definitely lethargic throughout the day after she had been given the wrong medication. LPN BB reported that the facility would typically complete a follow up education after a medication error, but that she had not yet received any additional education since she had administered the wrong medication to Resident #65. In an interview on 9/17/2025 at 9:47 AM, Registered Nurse Supervisor (RN-S) AAA reported that she was made aware of Resident #65 receiving the wrong medication on 9/8/25 by LPN BB as soon as she had discovered the error. RN-S AAA reported that Resident #65 was monitored for 24 hours after the discovery of the incident and was noted to be more lethargic. RN-S AAA reported that she had not completed any follow up education with LPN BB after the incident, but that typically the facility's nurse educator would complete a follow up education. On 9/17/2025 at 10:22 AM, This writer attempted to reach Nurse Educator (NE) D via telephone. This writer was unable to speak to NE D prior to survey exit. Review of the facility's Administering Medications policy, last revised 8/26/2019, revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: . 2. Medications must be administered in accordance with the orders . 5. Nurses perform the triple check 6-rights of medication administration: Right Medication, Dose, Time, Route, Documentation, and Person .19. medications ordered for a particular resident may not be administered to another resident .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents. Findings include: During the initial tour of the kitchen, starting at 9:48 AM on 9/10/24, an interview with Food Service Director (FSD) Z found that the facility date marks potentially hazardous food items for a three-day discard. Observation inside the walk-in cooler found a half gallon of skim milk dated 8/18 to 8/21 and an open thickened dairy beverage dated 8/18 to 8/21. Observation of the preparation cooler, at 10:02 AM on 9/10/24, found a container of egg salad and a container of tomato soup with no dates to indicate the discard for each product. Further observation found an open package of hot dogs dated 9/5 to 9/8. Observation of the South dining room, at 11:15 AM on 9/10/24, found an open thickened cranberry juice with no date to indicate discard. the item states its good for 7 days after opening. Observation of the [NAME] Dining room, at 11:22 AM on 9/10/24, found two magic cups stored in the refrigeration unit with no date. The item states its good for 5 days after thaw. Observation of the Ritz dining room, at 11:36 AM on 9/10/24, found an open container of Med Pass 2.0 with no date to indicate discard. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During a tour of the walk-in cooler, at 9:50 AM on 9/10/24, it was observed that an accumulation of debris was evident on the floor and perimeter of the cooler. Accumulation consisted of butter packets, cherry tomatoes, and other vegetable matter with dirt and debris and heavy gunk around the feet of the storage racks. An interview with FSD Z found that the walk-in cooler should get swept and mopped weekly. FSD Z went on to state that he was off last week, and some tasks may not have been done. During an observation of the clean utensil rack, at 10:25 AM on 9/10/24, it was found that as clean dish racks are used to store clean utensils in a covered expediting cart, over time, crumb debris has made its way to the floor of the cart and is visibly accumulating. During an interview with FSD Z, at 10:35 AM on 9/10/24, it was found that the stand-up mixer gets used daily. When asked if the mixer had been used yet today, FSD Z was unsure. Observation of the mixer found some stuck on dried white splatter debris on the over arm of the machine and in the metal bowl used for mixing. FSD Z stated he would get the unit cleaned. During an interview with FSD Z, at 10:43 AM on 9/10/24, it was found that the front of house kitchen staff wipe down the surface of the ice machine, but maintenance takes care of the deep cleaning of the unit. Observation of the ice machine found an accumulation of black and tan debris inside the unit on the front facing portion where ice is made. When asked if the debris was staining over time, FSD Z was unsure. A clean paper towel was used to wipe the inside surface and found the debris was easily wiped away. Observation of the South dining room, at 11:14 AM on 9/10/24, found that the underside of the juice machine, between the spouts, was found to have sticky accumulation of debris with black spots on some surfaces. An interview with FSD Z found that he typically takes care of the juice machines himself, but being off last week they probably didn't get done. Observation of the [NAME] Dining room, at 11:22 AM on 9/10/24, found the refrigeration unit with ripped and torn gaskets on the side and bottom of the door. Further observation found an accumulation of lack debris around the bottom portion of the door and debris from an old spill inside the bottom of the unit. Observation of the Ritz dining room, at 11:35 AM on 9/10/24, found that the underside of the juice machine, between the spouts, was found to have sticky accumulation of debris with black spots on some surfaces. Observation of the refrigerator unit found an increased black debris in the gasket seals of the unit. An interview with Maintenance BB, at 1:55 PM on 9/10/24, found that they take care of the deep cleaning of the ice machine and that they are due for a cleaning. When asked about the accumulation inside the machine, Maintenance BB stated that dietary staff should be cleaning the surfaces as needed. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . Observation of the walk-in freezer, at 10:45 AM on 9/10/24, found a box of frozen raw burger patties open and exposed with no cover or container to protect the quality and safety of the product. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings; During a tour of the dish area, at 11:49 AM on 9/10/24, observation of the high temperature dish log didn't find any inconsistencies showing the machine was not working properly. After running the high temperature conveyor dish machine, three times with a maximum registering dish plate thermometer, it was found that the internal temperature was not achieving 160F or higher, even after the facilities heat sensitive tape was used to check the machine. It was also observed that during these cycles, the rinse pressure was found to range between 40-50 pounds per square inch (psi). An interview with Dietary Aide AA found that the pressure is typically 35-45 psi. Observation inside of the machine found accumulation of calcium, lime, and gunk debris on the spray arms, with visible debris blocking portions of some spray nozzles. Gauges of the machine at this time were reading 185-190 for rinse and 160-165 for the wash. When asked about how often the machine is delimed, FSD Z stated it was due. A revisit to the dish machine, at 1:20 PM on 9/10/24, found that the rinse pressure maintained a 35-45 psi for the multiple loads and the dish plate thermometer was still unable to achieve a 160F contact According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: (1) For a stationary rack, single temperature machine, 74C (165F); or (2) For all other machines, 82C (180F). According to the 2017 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch).

Based on observation, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Properly restrain facial hair while working with food; 3. Ensure proper working order of dish machine; 4. Clean non-food contact surfaces to sight and tough; and 5. Ensure proper cooling of potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 94 residents who consume food from the kitchen. Findings Include: 1. In an observation on [DATE] beginning at 11:40 a.m., reviewed the main facility kitchen. Observed two large, white, rolling bins below the counter, which contained flour and sugar. No dates noted to indicate when these items were placed in the bins (no open dates or use by dates). In an observation on [DATE] beginning at 11:40 a.m., reviewed the main facility kitchen. Observed the following items in the reach-in cooler: An opened 12 ounce container of [NAME] mayonnaise, with no open or use by date. An opened 8 ounce jar of Horseradish, with no open or use by date. An opened container of [NAME] sauce, with an open date of [DATE] and a discard date of [DATE]. An opened container of teriyaki sauce with an open date of [DATE] and a discard date of [DATE]. An opened 5 pound container of orange sauce, with no open or use by date. A plastic container of diced pears, with no label, open date, or use by date. An opened one gallon container of Italian dressing, with no open or use by date. An opened one gallon container of enchilada sauce, with an open date of [DATE] and a discard date of [DATE]. An opened one gallon container of barbeque sauce, with no open or use by date. A large metal tray of coleslaw, with a prepared date of [DATE] and a use by date of [DATE]. A metal tray of hot dogs, with no label, open date, or use by date. An opened 48 ounce bottle of lemon juice, with an open date of [DATE] and a use by date of [DATE]. A container of cherry pie filling, with an open date of [DATE] and a use by date of [DATE]. Two metal trays with no labels, open dates, or use by dates. One contained hot dogs and the other macaroni and cheese. In an observation on [DATE] beginning at 11:40 a.m., reviewed the main facility kitchen. Observed an opened 10 pound, 14 ounce container of syrup on the rack below the spices. No open date or use by date noted on the bottle. In an observation on [DATE] beginning at 11:40 a.m., reviewed the main facility kitchen. Observed the following items in the walk-in cooler: An opened 48 ounce bottle of lemon juice, with no open or use by date. Four 4 ounce vanilla health shakes, with no date noted to indicate when the shakes were pulled from the freezer. In an interview on [DATE] at 11:55 a.m., Director of Dining Services LLL reported the coolers should be checked daily for appropriate labeling/dating and expired food items should be discarded. Review of the policy/procedure Food and Supply Storage, dated ,d+[DATE], revealed .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label . 2. In an observation on [DATE] beginning at 11:40 a.m., reviewed the main facility kitchen. Observed Cook CCC as he prepared pureed corn muffins for the dinner meal. Noted Cook CCC had visible facial hair, with no beard net/restraint in use. Review of the policy/procedure Uniform Dress Code, dated ,d+[DATE], revealed .Associates Working with Food .Wear the approved hair restraint when on duty regardless of length or presence of hair .Restrain all facial hair with a beard net/restraint . 38905 1. During a tour of the west dining room, at 10:30 AM on [DATE], it was observed the following items were not dated or held passed their discard dates: a thickened dairy beverage dated ,d+[DATE] to ,d+[DATE], thickened lemon water dated ,d+[DATE] to ,d+[DATE], thickened nectar water dated ,d+[DATE] to ,d+[DATE], thickened orange juice dated ,d+[DATE] to ,d+[DATE], and two magic cups that stated to be consumed within five days after thaw. According to the 2017 FDA Food Code section ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 3. During a tour of the main kitchen dish machine, at 9:45 AM on [DATE], a review of the facilities Dishmachine Temperature Record (High Temperature Dishmachine), dated [DATE], found 18 logged wash temperatures were below the required 160F listed on the machines data plate. Further review of the log found that it was not being consistently tracked with numerous missing entries for the month. An interview with Director of Dining Services (DDS) LLL found that he was unaware the requirement was 160F and not 150F. Starting at 9:46 AM on [DATE], it was observed that four cycles of the dish machine were run and found the rinse pressure would rise to ,d+[DATE] pressure per square inch (psi) each time the rinse cycle was engaged. A review of the dish machines data plate found that it requires a rinse pressure of 20 +/- 5 psi. During a revisit to the kitchen, at 12:50 PM on [DATE], it was observed that the rinse pressure reached 60 psi two cycles in a row. An interview with DDS LLL, at 1:40 PM on [DATE], found that the vendor came to fix the dish machine, but will need to come back in order to work on the rinse pressure. According to the 2017 FDA Food Code section ,d+[DATE].110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: .(3) For a single tank, conveyor, dual temperature machine, 71C (160F) . According to the 2017 FDA Food Code section ,d+[DATE].113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). 4. During a tour of the main dining room, at 10:03 AM on [DATE], an interview with DDS LLL found that dietary staff clean the juice and coffee machines daily. During an observation of the underside of the juice machine, it was observed that spotted accumulation was found on the left underside of the unit. During a tour of the Ritz dining room, at 10:15 AM on [DATE], observation of the underside of the juice machine found accumulation of dark spotted debris on the left underside of the unit. During a tour of the front dining room, at 10:18 AM on [DATE], observation of the underside of the juice machine found increased accumulation of dark spots on the left underside of the unit. According to the 2017 FDA Food Code section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5. During the start of the kitchen tour, at 9:04 AM on [DATE], it was observed that large pork loins had just been taken out of the oven and were resting on the preparation table. During a revisit to the kitchen, at 11:50 AM on [DATE], a tour of the walk-in cooler found a pan on an expediting rack with a large pork loin. The temperature at this time was found to be 87F. When asked what time the pork loin started cooling. Executive Chef MMM stated that it had only been a handful of minutes, when asked what time the temperature of the pork loin hit 135F (the temperature cooling starts at) Executive Chef MMM was unsure. DDS LLL had the pork loin discarded According to the 2017 FDA Food Code section ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less .

Based on observation, interview, and record review the facility failed to provide a dignified dining experience in 11 residents (Resident #11, #395, #78, #73, #18, #34, #44, #53, #41) observed during dining, from a total sample of 20 residents, resulting in the potential for decreased self-esteem and feelings of disappointment with the dining experience. Findings include: During an observation on 08/30/23 at 08:28 AM in the west dining room, eight residents (Resident #11, #395, #78, #73, #18, #89, #34, and #35) were seated at tables, 5 CNA's (Certified Nursing Assistant) were waiting for trays to be prepared and Kitchen Staff (KS) EEE was plating food. At 8:32 AM a cart with 6 meal trays, for residents that were eating in their rooms was wheeled out of the dining room. During subsequent observations on 08/30/23 at 8:33 AM, an additional unknown female resident walked into the west dining room and was immediately served her breakfast. Resident #395 was observed sitting at a table alone, watching the staff preparing trays and twiddling his thumbs. At 8:34 AM, Resident #11, who was sitting alone at a table in front of Resident #395, was served his breakfast and CNA UU sat down and began feeding Resident #1. At 08:39 AM, Resident #35, who was sitting at a table alone towards the back of the room was served her tray, and CNA EE sat down and began to feed Resident #35. At 08:39 AM, Resident #395 sighed and looked around the room, then was observed unfolding his napkin, rearranging his utensils and rocking back and forth in his wheelchair. At 08:43 AM, CNA II served Resident #395 his breakfast tray and the resident immediately began eating. During the same observation as above in the west dining room on 08/30/23 at 08:35 AM Resident #89 was served her breakfast tray, and began eating; Resident #34 and Resident #18 were both sitting at the table with Resident #89 and were served at nearly the same time, but were not assisted with their meal. At 08:46 AM (10 minutes later), CNA II assisted Resident #34 and #18 with their meals. During the same observation as above in the west dining room on 08/30/23 at 08:38 AM Resident #78 and Resident #73 were sitting together at a table, and were served their trays, but were not able to feed themselves. Then at 08:56 AM CNA UU stopped feeding Resident #11 and began assisting Resident #78 and Resident #73 with their meals. CNA UU was observed standing at the table and taking turns giving bites of food to Resident #78 and Resident #73. Review of an Admission Record revealed Resident #395 was originally admitted to the facility on [DATE]. Minimum Data Set (MDS) assessment for Resident #395 was not availbale due to recent admission. Review of Resident #395's Kardex (care guide) indicated that he needed set, and assist as needed for meals. In an interview on 08/30/23 at 09:50 AM, Resident #395 reported that it was frustrating, but that he was getting used to being the last resident served in the dining room. In an interview on 08/30/23 at 11:41 AM, CNA UU reported that the meal service process is to serve independent residents first, but that she decided to sit down and feed Resident #11 first because she knew that he would take the longest. CNA UU reported that she does not sit down when she feeds residents, but prefers to stand so that they can see her. In an interview on 08/30/23 at 08:49 AM, Kitchen Staff (KS) EEE reported that the facility process is to serve residents that eat independently first, but that she did not see Resident #395, until after everyone else had been served. In an interview on 08/30/23 at 10:13 AM, CNA II reported that the breakfast meal in the west dining room did not go well this morning and stated, .there must have been some miscommunication. CNA II reported that Resident #395 and #89 were independent and should receive their trays first, Resident #11, #34, #35, #73, and #78 were dependent on staff for eating, and Resident #78 and #18 needed a lot of assistance. 47955 Resident #44 Review of an Admission Record revealed Resident #44 had pertinent diagnoses which included Alzheimer's Disease, Dementia with other disease classified elsewhere, unspecified severity with other behavioral disturbances, and age-related debility. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 6/7/23, revealed Resident #44 had severe cognitive impairment. During an observation on 8/28/23 at 12:50 PM, 4 residents were seated in wheelchairs at the table closest to the sink near an exit door in the front dining room. Resident #41 and Resident #14 were seated next to each other with Unit Coordinator (UC) SS seated between them. UC SS was verbally cuing Resident #14 to eat her lunch while feeding Resident #41 her lunch. Resident #44 and Resident #53 were also seated in wheelchairs at the same table. Resident #53 and Resident #44 both had a plate of food in front of them, but neither were feeding themselves nor were any staff present to assist them to eat. During an observation on 8/28/23 at 12:59 PM, Certified Nurse Assistant (CNA) VV was sitting at the table next to Resident #44 feeding her lunch. During an interview on 8/28/23 at 1:25 PM, CNA VV reported she was working on the East wing, and there were two CNAs assigned to the East wing today. CNA VV reported that one East wing CNA comes to the dining room to assist dependent residents to eat meals. CNA VV reported there are 4 residents that are either dependent and/or require assistance to eat meals in the front dining room. During an observation on 8/29/23 at 11:55 AM meal service in the front dining room began. Resident #44 was seated in a wheelchair at the table closest to the sink near an exit door, alone. During an observation on 8/29/23 at 12:15 PM, Resident #53 was seated in a wheelchair at the table with Resident #44. Resident #53 was served lunch. Resident #44 was not served lunch. No staff member was present at the table. During an observation on 8/29/23 at 12:21 PM, CNA WW served Resident #44 her meal and assisted her to eat. During an interview on 8/29/23 at 2:45 PM, Registered Nurse (RN) N reported Resident #44 was unable to eat or drink independently. RN N reported that Resident #44 was no longer able to hold a cup to drink from or silverware to eat with. During an interview on 8/29/23 at 3:17 PM, Activities Assistant (AA) YY reported that CNAs should assist dependent residents to eat. AA YY reported dependent residents had to wait for someone to be available to assist them to eat and are served at the end of meal service. AA YY reported someone from nursing should feed dependent residents. AA YY' reported she was not trained to assist with feeding dependent residents. During an interview on 8/30/23 at 8:57 AM, CNA AA reported she was working on the East wing, and there were three CNAs assigned to the East wing today. CNA AA reported that one East wing CNA comes to the dining room to assist dependent residents to eat meals. CNA AA reported there are 4 residents that are either dependent and/or require assistance to eat meals in the front dining room. During an observation on 8/30/23 at 11:51 AM, Resident #44 and Resident #14 were seated in wheelchairs at the table closest to the sink and an exit door in the front dining room for lunch. Resident #14 was served lunch. Resident #44 was not served lunch. During an observation on 8/30/23 at 11:55 AM, Resident #53 was seated in a wheelchair at the table closest to the sink and an exit door in the front dining room and served lunch. Resident #44 was still seated at the same table and was not served lunch. During an observation on 8/30/23 at 12:05 PM, Resident #44 was the only resident in the front dining room that was not served food or eating. There were 15 residents present in the front dining room. Two other residents, Resident #14 and Resident #53 present at the same table as Resident #44, both were eating and/or being assisted to eat. Resident #44 was not served. During an observation on 8/30/23 at 12:07 PM, Resident #44 was served lunch by CNA AA. CNA AA said to Resident #44 I'll be back to feed you soon. During an observation on 8/30/23 at 12:12 PM, CNA AA sat at the table near the sink and an exit door in the front dining room and gave Resident #44 the first bite of her lunch. During an interview on 8/30/23 at 12:47 PM, Director of Nursing (DON) B reported there was no specific staffing schedule for nursing staff related to meal service in the front dining room. Review of Kardex on 8/29/23 for Resident #44 revealed .eating dependent .up in wheelchair for lunch and dinner . Review of a Care plan on 8/29/23 for Resident #44 revealed .has an ADL Self Care and Mobility Performance Deficit r/t (related to) .dementia .and comprehension of cues may contribute to varying levels of participation and assistance needed .initiated 11/14/18 and revised 6/8/23 .Eating Dependent . Review of a MDS assessment for Resident #44, dated 6/7/23, revealed ADL Self-Performance section H eating- how resident eats and drinks regardless of skill .score 1. Self-Performance coded a 3 (Extensive assistance- resident involved in activity, staff provide weight bearing support) and 2. Support coded a 2 (One Person Physical Assist).

Based on observation, interview, and record review, the facility failed to (1) obtain a physician order for medicated topical skin creme and (2) prevent Certified Nursing Assistants from administering medicated topical skin cream required to be administered by licensed nursing staff for 1 resident (Resident #8) of 2 residents reviewed for skin conditions, resulting in the potential for residents to have received inappropriate or inadequate care, lack of communication among care providers, and the potential for the residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #8 In an observation on 8/28/2023 at 12:02 in Resident #8's room, Resident #8 asked Certified Nursing Assistant (CNA) EE to put Biofreeze Cream on his legs. Two tubes of Biofreeze Cream were found in Resident #8's bedside drawer and rubbed onto his legs and feet by CNA EE. Review of Resident #8's electronic medical record on 8/28/2023 at 12:15 PM revealed no order for Biofreeze Cream. In an interview on 8/28/2023 at 12:26 PM, CNA EE reported CNAs are allowed to administer Biofreeze Cream and Biofreeze Cream did not require a physician order. In a telephone interview on 8/29/2023 at 3:17 PM, CNA XX reported Resident #8 asked her to place Biofreeze Cream on his leg when she responded to his call light at approximately 5:40 AM on 8/26/2023. CNA XX reported she found Biofreeze Cream in Resident #8's bedside drawer and rubbed it onto his leg. In an interview on 8/28/2023 at 12:29 PM, Registered Nurse (RN) Nursing Supervisor G reported use of Biofreeze Cream at the facility required a physician order, should be locked in the treatment cart, and must be administered by licensed nurses and not by CNAs. RN Nursing Supervisor G reviewed Resident #8's electronic medical record and reported he did not have a physician order for Biofreeze Cream. In an interview on 8/29/2023 at 12:25 PM, Assistant Director of Nursing (ADON) D reported she reviewed Resident #8's electronic medical record and did not see a past order for Biofreeze Cream. ADON D reported that although Biofreeze Cream is an over-the-counter product, it is medicated and CNAs cannot administer it to residents. ADON D reported Biofreeze Cream required a physician order, must be stored in the treatment cart, and must be applied by licensed nursing staff. Review of facility policy/procedure Administering Medications, revised 8/26/2019, revealed .Only (facility) licensed nurses administer and document the administration of medications . Medications must not be left unattended and accessible to unlicensed personnel or residents/visitors .

Based on interview and record review, the facility failed to discontinue psychotropic PRN (as needed) medications after 14 days and/or document clinical rationale and indicate a timeframe for extend PRN psychotropic medication use in 1 of 5 residents (Resident #38) reviewed for psychotropic medications, resulting in the potential for unnecessary medication use and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #38 Review of an Admission Record revealed Resident #38 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and anxiety. Review of Resident #38's Physician Orders revealed, Xanax Oral Tablet 0.5 MG (Alprazolam) (a medication used to treat anxiety) Give 1 tablet by mouth as needed for Anxiety/Agitation Not to exceed to 2.0mg per day with scheduled dose. Active 7/10/2023 at 2:30 PM. The medication order did not include a stop date. In an interview on 08/30/23 at 11:06 AM, Nursing Supervisor (NS) OOO reported that Resident #38 had PRN Xanax ordered on 7/10/23 due to having some distressing thoughts about dying, but she was not sure if the resident was still having these thoughts. NS OOO reported that PRN Xanax should be written with for 14 days, but that Resident #38's order was not given a stop date. NS OOO reported that the nursing supervisor reviews the orders and should have caught the error. In an interview on 08/30/23 at 11:20 AM, Social Worker (SW) HHH reported that the facility policy is to always put a 14 day end date on PRN psychotropic medication orders. SW HHH reported that Resident #38's PRN Xanax written on 7/10/23 was not given a stop date, the doctor did not write a rationale for the medication order to be written indefinitely. SW HHH reported that the facility does not have a process for writing rationale for PRN psychotropic medications to be written for more than 14 days and stated, .we just don't do it . SW HHH reported that it is the responsibility of the SW to double check that orders are entered correctly. SW HHH reported that the incorrect order should have been caught on 8/10/23 at the monthly review of medications. In an interview on 08/30/23 at 01:32 PM, DON reported that the physician did not indicate a rationale or specify a date for Resident #38's PRN Xanax to be reviewed. Review of Resident #38's Medication Administration Record indicated that Resident #38 received doses of PRN Xanax on 7/14/23, 7/26/23 and 8/27/23. Review of Resident #38's Behavior Log (utilized by the direct care staff) revealed, no behaviors documented. Review of Resident #38's Psychotropic Medication Review dated 7/13/23 revealed, .Use of PRN medications .Xanax 1 time for increased anxiety, restlessness .ineffective .Team Recommendations: Recommend the following changes: please consider writing Xanax PRN order for 14 days per State Regulation. Physician response and signature: wrote clarification order regarding hospice care. Review of Resident #38's Psychotropic Medication Review dated 8/10/23 revealed, Use of PRN medications .Xanax 3 times for increased anxiety, delusions, effective one time .Team Recommendations: No Change. An attempt was made to review a facility policy for PRN Psychotropic medications, which revealed that there was no written policy in developed.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services out of the facility's total census of 78 residents. Findings include: On [DATE] between 6:50 AM, and 7:30 AM, during a tour of the dietary environment the following non-food contact surfaces were observed soiled and with an accumulation of dust and debris: On the flooring in the main kitchen preparation area. On the interior of both two-door reach in refrigerators. On the interior of both upright reach in food warmers. Underneath the dish machine. On the ceiling above the food prep and cook line. On seven ready for use Cambro containers. On [DATE] between 10:47 AM, and 11:28 AM, during a tour of the dietary environment the following food contact surfaces were observed soiled and with an accumulation of dust and debris: On the manual number 10 handheld can opener. Within the interior of the kitchen's microwave. On [DATE] at 12:19 PM, upon interview with the Dietary Manager, staff J, on the current state of the kitchen flooring they stated, we do the best we can to keep to the cleaning schedule posted on the reach in refrigerator. On [DATE] at 12:40 PM, upon record review of cleaning logs entitled, Cleaning list dated, [DATE] and a, Master cleaning list with no date provided, the surveyor confirmed that the facility has individual tasks in place to achieve a clean and sanitary environment in the kitchen, its support spaces, and equipment throughout the week, however the tasks were not initialed to identify their completion on a consistent basis. On [DATE] at 12:43 AM, the surveyor inquired with staff J if they thought the listed items were being consistently completed as required to which they responded, no, probably not. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils directs that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On [DATE] at 8:50 AM, one gallon of skim milk with an expiration date of, [DATE] and one gallon of whole milk with an expiration date of, [DATE] were observed with datemarking stickers identifying a discard date of, [DATE] in the [NAME] dining room's reach in refrigerator. At this time upon interview with Dietary Manager, staff J, as to dates listed on the containers they stated, I'm not sure how these were missed. Beverages should have been served from the main dining room over here. I will make time to educate the staff on this. On [DATE] at 10:17 AM, a half case of nourishment shakes was observed ready for use in the front kitchenette's reach in cooler with an expiration date of [DATE] on each of the cartons. At this time upon interview with staff J, the surveyor asked who was responsible for the checking of expired items in the walk-in cooler to which they replied, the people receiving the food and our staff as well. We had a shortage of these a little while ago and this case I believe was brought in from a family member for one of the residents. I'll get rid of these now. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition directs that: (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; P (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). P On [DATE] at 11:12 AM, the two-door prep reach in refrigerator was observed with its exterior temperature gauge reading 46 degrees F. At this time the surveyor inquired with Dietary Manager, staff J, on how the facility monitors the temperatures of the refrigeration units to which they stated, we check them daily. The surveyor then asked staff J if the facility takes food temperatures prior to serving from this unit to which they stated, no, not normally but we can. On [DATE] at 11:13 AM, observation by the surveyor of the refrigerator's internal thermometer revealed a temperature reading of 48 degrees F. On [DATE] between 11:14 AM, and 11:17 AM, the following food product temperatures were verified via staff J's thermometer probe: A tray of individually portioned cottage cheese cups at 47 degrees F A tray of individually portioned melon-based fruit cups at 50 degrees F A tray of individually portioned salads containing cut tomatoes at 63 degrees F On [DATE] at 11:17 AM, the surveyor inquired with staff J what the facility would normally do in a situation like this to which they stated, throw them out and make new. At this time staff J was observed instructing staff to not serve anything from the cooler. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. During initial tour of the facility kitchen on [DATE] at 2:15 PM., it was noted the coffee machine had a heavy accumulation of coffee splatter buildup on the face of the machine. Noted a storage rack which had a dish tub of random covers/lids for cambros (clear food storage bins) and clear plastic water pitcher lids which were wet with water. The cambros were noted to be etched/scored. Noticed on the storage rack approximately 10 blue rimmed plates which were etched and scored with dried food particles stuck on. Observed the dishwasher which was heavily soiled on the front, sides, and bottom (near the floor) with dried stuck on residue, and food particles. Noted underneath near the grease trap on the floor approximately ,d+[DATE] small ants crawling around. Noted the floor underneath the dishwasher was heavily soiled with dust, debris, food crumbs and grime. Observed the drying dish rack which had numerous bowls, cups and plates which were heavily stained with dark coffee, and food stains. Bowls and utensils had dried stuck on food particles and dried oatmeal stuck in and on the some of the bowls. In an interview on [DATE] at 2:45 PM., Dietary Manager (DM) J reported dishes on the drying rack should be clean with no food particles, and the dark staining(s) should be removed by dip it a cleaning solution that removes dark coffee stains, and dark food stains out of plastic dishware. Observed a cooled Deli Board (cold stainless steel storage container for deli style meats, cheeses and vegetables). Noted (not limited to) ham, boiled eggs, cheese, pepperoni, turkey and salad vegetables) all labeled with a expired date of [DATE]. Noted in a reach in cooler next to the Deli Board 4-chef salads (salads with meat, cheese and egg) were not labeled or dated. In an interview on [DATE] at 3:10 PM., DMJ reported the deli foods/meats inside the Deli Board should have been discarded yesterday ([DATE]). DM J reported the salads in the reach in cooler should be dated. DM J reported the salads were made up from food items from the Deli Board and should have been discarded as well. Review of 2013 U.S. Public Health Service Food Code, ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking directs that: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. During an observation on [DATE] at 3:30 PM., the walk in freezer was noted to have a heavy accumulation of frozen water condensation on the freezer compressor fan blades. Noted a moveable shelf underneath the compressor which had boxes of frozen food items with large chunks of ice frozen on top of the boxes of food, on the shelf itself and floor underneath the compressor and shelf. Noted on the floor below the compressor were numerous areas of ice buildup which were from compressor. In an interview on [DATE] at 3:35 PM., DM J reported the freezer compressor has been dripping water condensation. DM J reported he has not put in a work order for the compressor to be looked at. DM J reported the shelf with boxes of food items should not be placed underneath the compressor, and the ice build up on shelf, and floor should have been cleaned up. Review of 2013 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Good Repair and Proper Adjustment directs that: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE].

Based on observation, interview, and record review, the facility failed to ensure access to a call light in 2 of 18 sampled residents (Resident #45 and Resident #58) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs. Findings include: According to https://www.ncbi.nlm.nih.gov, .Call light technology serve as a means of communication for patients to their care providers that are outside of the patient's room. This technology is a direct link to getting their needs met and the care provided by nurses . Resident #45: Review of an Admission Record revealed Resident #45 was a male with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 8/5/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15, which indicated Resident #45 was cognitively intact. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 8/5/2022, revealed, .Section GG: Transfer: Extensive Assistance, Two person physical assist .Locomotion on unit with wheelchair: Total Dependence, One person physical assist .Walking: Activity did not occur . Review of current Care Plan for Resident #45, revised on 2/4/21, revealed the focus, .(Resident #45) is at risk for falls r/t (related to): Deconditioning, Gait/balance problems, left sided weakness post stroke, bilateral leg [CONDITION(S)], [CONDITION(S)] (high blood pressure), medications, osteopenia, and incontinence . with the intervention .Be sure the call light is within reach and encourage use. Prompt response to all requests for assistance .(Resident #45) needs a safe environment with: a working and reachable call light . During an observation on 9/27/22 at 3:38 PM, Resident #45 was observed seated in his room in his wheelchair in the middle of his room watching television. Resident #45's call light was observed laying on the rolling bedside table which was pushed up against the wall next to the entrance to the bathroom door. In an interview on 9/29/22 at 2:22 PM, Certified Nursing Assistant (CNA) S reported when the nursing staff assists a resident when they leave the room, the staff were to ask if the resident needs anything else prior to leaving, ensure all fall interventions were in place, and place the resident's call light in reach so they would be able to call for assistance. In an interview on 9/29/22 at 2:34 PM, CNA EE reported when staff were finished assisting a resident, they were to ensure the call light was in reach for the resident to call for assistance prior to leaving the room. Review of policy, Call Lights: Accessibility and Timely Response reviewed/revised on 1/20/22, revealed, .5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Resident #58 Review of an Admission Record revealed Resident #58 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of 8/23/2022, revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicated that Resident #58 was severely cognitively impaired. Review of a current activities of daily living Care Plan intervention for Resident #58, with a revision date of 3/28/2022, directed staff to encourage use of call light to call for assistance. In an observation on 9/28/2022 at 8:25 a.m., Resident #58's call light was curled up at the foot of his bed and not within his reach.

Based on observation, interview, and record review the facility failed to clean resident shared equipment, bath & shower rooms, as well as high touch surfaces such as beverage carts resulting in the potential for bacterial harborage, cross-contamination, and the spread of disease to a vulnerable population. Findings include: During an observation on 6/28/21 at 12:45 PM., observed a vitals machine on the west hall parked next to the medication cart and room [ROOM NUMBER]. The finger probe (measures blood oxygen levels) was visibly soiled in the crevasses. A wireless single finger probe was also noted to be soiled with grime in the crevasses. The outside of the probe had a piece of medical tape adhered to it, which was dirty in appearance, and a non-cleanable surface. During an observation on 6/28/21 at 12:56 PM., observed the shower room on the west hall. Noted the privacy curtains were visibly soiled with dried brown substance on the 2nd curtain, and the top of the hangers were not attached correctly. Observed on the floor in front of the toilet a white bucket (from a portable toilet commode) which was soiled with feces on the outer side of the bucket. A shower chair was observed in the 2nd shower stall which was visibly soiled with dried urine and feces splatter on the underneath part of the seat. During an observation on 6/28/21 at 12:48 PM., observed a treatment cart with a single oxygen finger probe on top of cart. The finger probe was visibly soiled in the crevasses and had 2 types of tape on the exterior portion of the probe which was tattered and dirty in appearance. During an observation on 6/28/21 at 12:51 PM., observed 3 black beverage carts on the west hall. All 3 carts were noted to be visibly soiled on the shelves, the handles, as well as the exterior sides and frame of the carts. There was a buildup of dried crusted spillage, on the shelves of all 3 carts. During an observation on 6/28/21 at 1:08 PM., observed a vitals machine parked outside room [ROOM NUMBER]. The blood pressure cuffs were both visibly soiled. The base of the machine was also noted to be soiled. The finger probe was noted to have grime in the crevasses. During an interview on 6/28/21 at 1:12 PM., Licensed Practical Nurse (LPN) R reported the Certified Nurse Aides (CNA's) clean the equipment before and after each use. During an observation on 6/28/21 at 1:17 PM., observed the south hall Bath room. The 2nd privacy curtain was visibly soiled, along with having a hole near the top. The curtain was missing hooks to properly hang the curtain. Observed the shower chair with a green mesh back, heavily soiled underneath the seat was dried urine stains, a heavy accumulation of dried urine buildup in the crevasses of the frame where the seat meets the frame. During an observation on 6/28/21 at 1:25 PM., observed a vitals machine outside room [ROOM NUMBER] the blood pressure cuff was heavily soiled, the finger probe was soiled in the crevasses. Observed on the treatment cart next to room [ROOM NUMBER] noted 2 blood pressure cuffs in a bath basin (no water in it) both visibly soiled, also observed was a temporal thermometer (no-touch type) had medical tape around the bottom, which was dingy, tattered and an unclean surface. During an observation on 6/28/21 at 1:31 PM., observed a sit to stand lift on the west hall, the base where residents plant their feet to stand was noted to be heavily soiled with dust and debris. The blue knee pads which stabilize the residents' legs while standing were noted to be soiled with a dried crusted substance. During an interview on 6/28/21 at 1:19 PM., CNA J reported lifts, and vital machines are to be cleaned between uses. CNA J reported the shower chairs are cleaned after each use. CNA J reported if a staff member notices something is dirty, they should clean it, or ask for help from Housekeeping (Hsk). During an observation on 6/29/21 at 10:46 AM., observed a sit to stand lift on the west hall, the base where residents plant their feet to stand was noted to be heavily soiled dust and debris. The blue knee pads which stabilize the residents' legs while standing were noted to be soiled with a dried crusted substance. During an observation on 6/29/21 at 10:48 AM., observed the south hall Bath room the 2nd privacy curtain was visibly soiled, along with having a hole near the top. The curtain was missing hooks to hold it completely up in 5 of the 14 eye hooks. Observed the shower chair with a green mesh back, heavily soiled underneath with dried urine stains and dried urine buildup in the crevasses of the frame where the seat meets the frame. During an observation on 6/29/21 at 12:47 PM., observed a sit to stand lift on the west hall parked near room [ROOM NUMBER]. The base of the lift where residents plant their feet to stand was noted to be heavily soiled with dust and debris. The blue knee pads which stabilize the residents' legs while standing were noted to be soiled with a dried crusted substance. During an observation on 6/29/21 at 12:53 PM., observed the south hall Bath room the 2nd privacy curtain was visibly soiled, along with having a hole near the top. The curtain was missing hooks to hold it completely up in 5 of the 14 eye hooks. Observed the shower chair with a green mesh back, heavily soiled underneath with dried urine stains and dried urine buildup in the crevasses of the frame where the seat meets the frame. During an observation on 6/29/21 at 12:56 PM., observed a vitals machine outside room [ROOM NUMBER] the blood pressure cuff was heavily soiled, the finger probe was soiled in the crevasses. Observed on the treatment cart next to room [ROOM NUMBER] there were 2 blood pressure cuffs in a water basin (no water) both visibly soiled, also observed was an electronic infrared thermometer with medical tape around the bottom, which was dingy, tattered and an unclean surface. During an observation on 6/29/21 at 1:00 PM., observed the shower room on the south hall. Noted under the toilet seat of the commode, on the frame was feces in numerous spots. During an observation on 6/29/21 at 1:06 PM., observed a black beverage cart outside room [ROOM NUMBER]. The cart was noted to be visibly soiled on the shelves, the handles, as well as the exterior sides and frame of the carts. There was a buildup of dried crusted spillage, on the shelves of the cart. During an observation on 6/29/21 at 1:08 PM., observed a vitals machine plugged in across from room [ROOM NUMBER]. The blood pressure cuff was heavily soiled, the 2 single finger probes were noted to be soiled in crevasses. During an observation on 6/29/21 at 1:13 PM., observed a vitals machine on the dementia hall two blood pressure cuffs noted to be heavily soiled. The temporal thermometer was soiled with medical tape. The base of the machine was soiled with debris. The finger probe was heavily soiled and stuck together and could barely open when this surveyor attempted to inspect the inside of the probe, which was sticky. During an observation on 6/29/21 at 1:21 PM., noted in the dementia hall shower room the privacy curtains were soiled with dark dried spots. The shower chair with green mesh had a soiled frame with urine under seat. The toilet riser with a bucket was noted to be heavily rusted on the frame, on the front of the commode. The rust spots were covered with clear packaging tape. Noted on a wire shelf a shower chair footrest observed to be heavily soiled with dried dark yellow/orange-colored urine stains. While standing near the shelf and commode noted a strong urine smell. During an interview on 6/29/21 at 1:15 PM., CNA MM reported vitals machines, lifts and all resident shared equipment should be cleaned before and after each use. CNA MM reported the bath/shower room equipment (shower chairs, commodes, toilets etc.) should be cleaned by the CNA/staff member who is in the room with the resident as soon as that resident finishes the shower, or if they need to use that bath/shower room. CNA MM reported she does not think there is a daily log sheet that staff use to check a box, or a duty list that should be done. During an observation on 6/29/21 at 1:53 PM., observed a sit to stand lift on the west hall, near room [ROOM NUMBER] the base where residents plant their feet to stand was noted to be heavily soiled dust and debris. The blue knee pads which stabilize the resident while standing were noted to be soiled with a dried crusted substance. During an observation on 6/30/21 at 10:26 AM., observed a sit to stand lift on the west hall, near room [ROOM NUMBER] the base where residents plant their feet to stand was noted to be heavily soiled dust and debris. The blue knee pads which stabilize the resident while standing were noted to be soiled with a dried crusted substance. During an observation on 6/30/21 at 10:27 AM., observed in the west hall shower room, noted bowel movement (BM) debris in the commode, as well as brown specs on the commode seat. BM was also observed on the underside of the shower chair seat that was under the shower. The privacy curtain covering the commode was observed with a brown smear on left inside portion of the curtain halfway up from the floor. During an observation on 6/30/21 at 10:30 AM., observed a vitals machine on the west hall parked next to the medication cart. The finger probe (measures blood oxygen levels) was visibly soiled in the crevasses. A single finger probe was also noted to be soiled with grime in the crevasses and the outside of the probe had a piece of medical tape which was dirty in appearance, and a non-cleanable surface. During an observation on 6/30/21 at 10:31 AM., observed 3 black beverage carts on the west hall. All 3 carts were noted to be visibly soiled on the shelves, the handles, as well as the exterior sides and frame of the carts. There was a buildup of dried crusted spillage, on the shelves of all 3 carts. During an observation on 6/30/21 at 10:35 AM., observed 2 black beverage carts on the south hall. Both carts were noted to be visibly soiled on the shelves, the handles, as well as the exterior sides and frame of the carts. There was a buildup of dried crusted spillage, on the shelves of all both carts. During an observation on 6/30/21 at 10:37 AM., observed the south hall Bath/shower room. The 2nd privacy curtain was visibly soiled, along with having a hole near the top. The curtain was missing hooks to hold it completely up in 5 of the 14 eye hooks. Observed the shower chair with a green mesh back, heavily soiled underneath with dried urine stains and dried urine buildup in the crevasses of the frame where the seat meets the frame. During an observation on 6/30/21 at 10:39 AM., observed a vitals machine outside room [ROOM NUMBER] the blood pressure cuff was heavily soiled, the finger probe was soiled in the crevasses. Observed on the treatment cart next to room [ROOM NUMBER] there were 2 blood pressure cuffs in a water basin (no water) both visibly soiled, also observed was an electronic infrared thermometer with medical tape around the bottom, which was dingy, tattered and an unclean surface. During an interview on 6/30/21 at 10:42 AM., LPN KK reported the nurses take vitals for the residents. LPN KK reported the machines are to be cleaned after each use. LPN KK reported staff carry wipes in baggies in their pockets. LPN KK reported she was not sure why the infrared thermometer had tape on them. LPN KK reported they get a lot of use around here, so it may be to keep the bottom/battery cap on. During an observation on 6/30/21 at 10:51 AM., observed a vitals machine on the east hall parked next to the medication cart. The finger probe was visibly soiled in the crevasses. A single finger probe was also noted to be soiled with grime in the crevasses and the outside of the probe had a piece of medical tape which was dirty in appearance, and a non-cleanable surface. During an interview/observation on 6/30/21 at 10:53 AM., this surveyor and LPN V noted on the dementia hall shower room privacy curtains soiled with dark dried spots. The shower chair with green mesh had a soiled frame with urine under seat. The toiled riser with a bucket was noted to be heavily rusted on frame on front of commode. The rust spots were covered by clear packaging tape. Noted on a wire shelf was a shower chair footrest observed to be heavily soiled with dried dark yellow/orange-colored urine stains. While standing near the shelf and commode noted a strong urine smell. During an interview on 6/30/21 at 12:08 PM., Infection Control Preventionist (ICP) E reported staff should clean resident shared equipment before and after each use. ICP E accompanied this surveyor throughout the bath and shower rooms on each unit. ICP E reported there should never be soiled resident shared equipment. ICP E reported there should not be soiled tape over any surface, including thermometers, and rusted equipment. Review of a facility Policy and Procedure dated 6/2019 revealed: .Cleaning and Disinfection of Resident-Care Equipment: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Definitions: Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process of eliminating microorganisms, except spores, from inanimate objects, usually by chemical means. Single-use items are items that are designed to be used once, for only one person. Examples include thermometer probe covers, urinary catheters, and intravenous catheters. These items are to be discarded after use, and therefore, cleaning is not required. Reusable single-resident items are items that may be used multiple times, but for one resident only. Examples include bedpans, urinals, and disposable blood pressure cuffs/stethoscopes. Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. Policy Explanation and Compliance Guidelines: 1. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non- critical equipment. General guidelines include: a. Verily whether the equipment is single-use or reusable. Discard single-use items after use. b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff is responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule of once per shift as well as on 11-7. d. Multiple-resident use equipment shall be cleaned and disinfected after each use. e. Most equipment may be cleaned/disinfected in the areas in which the equipment is used. f. For durable medical equipment, such as feeding pumps, staff shall store used/dirty equipment in soiled utility room. Maintenance shall be responsible for terminal cleaning/disinfection in designated locations, covering the equipment to prevent dust and other contamination, and storing in clean utility or other designated storage rooms. g. Wear gloves when cleaning/disinfecting equipment. Wear gowns or face protection if splashes are expected during cleaning. h. Use only EPA-registered disinfectants with kill claims for the common organisms found in the facility. If the equipment is exposed to residents on transmission-based precautions, verify the disinfectants arc registered for use with the relevant organism. i. Verify the disinfectant is compatible with the equipment. j. Follow manufacturer recommendations for cleaning equipment . A review of the west shower room, at 12:36 PM on 6/28/21, found a foul odor in the shower with bowel movement (BM) debris observed in the commode, as well as brown specs on the commode seat. BM was also observed on the underside of the shower chair seat that was under the shower. The privacy curtain covering the commode was observed with a brown smear on left inside portion of the curtain halfway up from the floor. A review of the shower room near the front day room, at 12:42 PM on 6/28/21, found two brown smears on the curtain of the far shower, as well as BM on a shower chair bowl sitting near the toilet. It was also observed that a smear of BM was found on the underside of the shower chair under the far shower. A review of the shower room near the front day room, at 3:11 PM on 6/28/21, with Housekeeping QQ, found the shower room in the same condition, with two smears of BM on the shower curtain, shower bowl sitting near the commode with BM smear on the outside of the container, and BM smear on the underside of the shower chair. When asked who would be responsible for cleaning these surfaces, Housekeeping QQ stated, CNA's should clean the equipment between showering residents. When asked how shower curtains would get cleaned, Housekeeping QQ stated, usually housekeeping would get notified and either be able to clean the surface of the shower curtain onsite, or remove and launder curtain. A review of the west shower room, at 3:22 PM on 6/28/21, with Housekeeping QQ, found the room in the same condition as the previous observation. BM smear in the commode with brown specs on the seat of the commode, BM smear still observed on the shower curtain and BM smear on the underside of the shower chair. When asked if he could see brown smear on the shower curtain, Housekeeping QQ stated, yes.

Based on observation, interview, and record review, the facility failed to ensure transfers were completed with a gait belt and per plan of care in 1 of 3 residents (Resident #39) reviewed for falls, resulting in the potential for falls and injuries. Findings include: In an interview on 6/30/21 at 2:15 p.m., Unit Manager GG reported a gait belt should be utilized for transfers for Resident #39 at all times, and stated .that's our policy . Unit Manager GG reported Resident #39 requires one staff member for assistance with transfers to the toilet/in the bathroom, and two staff members for assistance with all other transfers. Review of an Admission Record revealed Resident #39 was a female, with pertinent diagnoses which included dementia with behaviors, [CONDITION(S)] (a condition where bones become weak and brittle), history of stroke with residual weakness, and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 5/12/21, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment. Further review of this MDS assessment revealed Resident #39 required extensive assistance for transfers and was unsteady and only able to stabilize with staff assistance for transfers and ambulation. Review of a CP (Care Plan) Face Sheet (a guide used by Certified Nursing Assistant (CNA) staff to provide care to residents) for Resident #39, updated 6/4/21, revealed .Transfers: HH1 (one staff assist) w/ (with) grab bar in bathroom .HH2 (two staff assist) for all other transfers . No documentation noted on Resident #39's CP Face Sheet to indicate that a gait belt was indicated but not used. Review of a current Care Plan for Resident #39 revealed the focus .(Resident #39) has an ADL (Activities of Daily Living) Self Care and Mobility Performance Deficit r/t (related to) CVA (stroke) w/ (with) [CONDITION(S)] (paralysis on one side of the body), weakness, inability to tolerate weight bearing activity . with interventions which included .TRANSFER: (Resident #39) requires (HH1) for transfers in bathroom and HH2 for transfers from bed to WC (wheelchair) . last revised 2/28/20. No documentation noted in Resident #39's Care Plan to indicate that a gait belt was indicated but not used. In an observation on 6/28/21 at 9:45 a.m., CNA J assisted Resident #39 with a transfer from her wheelchair to her bed, in her room. Observed CNA J position Resident #39's wheelchair near the bed, and directed Resident #39 to give her a hug. CNA J then stood with Resident #39 holding on her shoulders, and transferred Resident #39 to her bed. Resident #39 appeared weak, with extensive transfer assistance provided by CNA J. No gait belt was utilized for the transfer. Note only one staff member, CNA J, assisted with Resident #39's transfer from her wheelchair to her bed. Resident #39 was observed to be calm and cooperative throughout the transfer. In an interview on 6/28/21 at 9:50 a.m., CNA J reported staff do not utilize a gait belt when assisting Resident #39 with transfers because she is .sometimes combative with care . In an observation on 6/30/21 at 1:41 p.m., CNA VV and CNA WW assisted Resident #39 with a transfer from her wheelchair to her bed, in her room. CNA VV placed a gait belt on Resident #39 prior to the transfer. Noted Resident #39 was calm and cooperative with gait belt use. Observed CNA VV and CNA WW assist Resident #39 with a stand-pivot transfer from her wheelchair to her bed, using the gait belt. Extensive assistance was provided by staff for the transfer, and Resident #39 appeared weak and unsteady. In an interview on 6/30/21 at 1:45 p.m., CNA VV reported Resident #39 uses a gait belt .most of the time . except when in the bathroom because she holds onto the bar. CNA VV reported no issues with gait belt use for Resident #39. In an interview on 6/30/21 at 1:47 p.m., CNA WW stated .Usually when she is ready to transfer she is ready to transfer .she does pretty good (with the gait belt) . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition.A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking . Review of the policy/procedure Safe Lifting and Movement of Residents, revised October 2009, revealed .In order to protect the safety and well-being of staff and residents, and to promote quality care, (Facility Name) uses appropriate techniques and devices to lift and move residents .Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Gait belts are used for all residents who need stand by to extensive assistance with transfers and/or ambulation .It will be care planned when a gait belt is indicated but not used due to resident's condition or preference .The gait belt provides a secure, firm hold to help stabilize and manage residents during ambulation and transfers .

This citation pertains to Intake # MI 685. Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls in 1 of 6 residents (Resident #105) reviewed for falls, resulting in a fall with an acute clavicle fracture. Findings include: Review of the policy/procedure Falls Management/Incident Reporting, no date, revealed .It is the intent of (Facility Name) to prevent falls through a systematic program consisting of risk identification, assessment, care plan interventions, and monitoring .A fall is an uncontrolled, unplanned abrupt movement to the ground from a higher elevation .PERIODIC MONITORING .Care plan interventions are reviewed quarterly for applicability to the resident's current status/situation prior to and during the quarterly care conferences .INITIAL ASSESSMENT FOLLOWING A FALL .The resident care plan will be updated once the resident has been found medically stable with an intervention appropriate to help minimize likelihood of future falls . Review of the policy/procedure Fall Prevention Program, revised October 2010, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . Review of the policy/procedure Care Plans - Comprehensive, revised October 2010, revealed .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes . Review of an Admission Record revealed Resident #105 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 6/25/20, revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, with a reference date of 6/25/20, revealed Resident #105 required extensive assistance from staff for transfers and walking in her room, was not steady and only able to stabilize with staff assistance for transfers and walking, and had a history of [REDACTED]. Review of the CAA (Care Area Assessment) Worksheet for Resident #105, dated 7/1/20, revealed .has had two falls since last assessment. She is at risk for further falls and injury related to dementia with poor judgment and memory, imbalance, muscle weakness, and medication use. (Resident #105) has a hx (history) of vasovagal occurrences (a brief loss of consciousness caused by a sudden drop in blood pressure and heart rate) and significant orthostatic BPs (blood pressures) at times. She has the propensity to self transfer .The goal is for (Resident #105) to be free from falls and injury through the review date .A Tabs alarm (an alarm to notify staff when a resident attempts to stand unassisted - used for fall prevention) is pinned to her shirt when in her w/c (wheelchair) . Review of the current Care Plan for Resident #105 revealed the focus .at risk for falls/injury r/t (related to) dementia w/ (with) poor judgment & memory, Imbalance and muscle weakness, medication use, chooses to self-transfer and Hx of Falls, HX of vasovagal occurrences and significant orthostatic BP's (blood pressures) at times . last revised 3/31/20. Interventions include .Tabs alarm when in w/c. Pin Tabs alarm to clothing . last revised 4/10/20. In an observation on 8/26/20 at 1:39 p.m., heard an alarm sound in Resident #105's room. Observed Resident #105 leaning forward in her wheelchair, which set off her Tabs alarm. Observed staff respond immediately to Resident #105's room to redirect Resident #105 to sit in an upright position. Noted Tabs alarm was in place and functional at this time. Review of an Incident Report for Resident #105, dated 7/2/20 at 2:30 p.m., revealed .CNA (Certified Nursing Assistant) and Activities aid (sic) heard a loud thud in (Resident #105's) room and alerted nurse to her room. (Resident #105) had attempted to stand using her walker and fell down on what appeared to be her left side. She was laying on her floor parallel to her closet/tv. Her Tabs alarm was not pinned to the back of her shirt and was not sounding .Assessed for injury and her left shoulder is very sore to touch. Vitals taken and WNL (within normal limits). Used mechanical lift to pick her up and put her into bed. Called and received order to obtain x-ray of left shoulder .Sore left shoulder to touch and with slight ROM (Range of Motion). At rest she denies pain but when area touched she flinches .CNA forgot to put Tabs alarm back on after attempting to toilet . Review of a Health Status Note for Resident #105, dated 7/3/20 at 2:09 a.m., revealed .Resident fell Thursday afternoon 7/2/20 around 1430 (2:30 p.m.) onto her left side. Resident has been guarding her left arm, will not move it, and is complaining of pain in her left arm. An X-ray was performed showing an acute distal clavicle fracture, nondisplaced . In an interview on 8/26/20 at 9:45 a.m., Assistant Administrator C stated in regard to Resident #105's fall on 7/2/20 .the care plan was not followed . Assistant Administrator C reported the Certified Nursing Assistant (CNA) exited Resident #105's room after care was provided and forgot to reattach the Tabs alarm. In an interview on 8/26/20 at 2:04 p.m., CNA EE reported Resident #105's fall on 7/2/20 happened just before the end of the shift. CNA EE reported she went to toilet Resident #105, unhooked the Tabs alarm from Resident #105's clothing, and cued the resident to stand using the grab bar in the bathroom. CNA EE stated .she (Resident #105) became upset and started yelling. I helped her back out of the bathroom and told her I would come back .She was getting so agitated I stepped back to giver her space . CNA EE reported that when she left Resident #105's room she forgot to reattach the Tabs alarm. CNA EE reported Resident #105 fell approximately five minutes after she exited the room. In an interview on 8/26/20 at 2:20 p.m., Licensed Practical Nurse (LPN) N reported Resident #105 has a history of self-transfers and occasionally reaches for and tries to pick up things that are not there. LPN N stated often .there aren't warning signs of when she will be getting up . and reported the Tabs alarm is in place to help notify staff when she may be attempting to transfer without assistance. LPN N stated .She (Resident #105) can be really spontaneous .Often she is leaning forward . LPN N reported when he entered Resident #105's room after her fall on 7/2/20 .she was on the ground with the walker beside her . LPN N reported prior to the fall he was at the nurses desk, and stated .you could hear the thud. We all pretty much got up right away . LPN N reported no alarm sounded at the time of Resident #105's fall. LPN N reported Resident #105 has had the Tabs alarm .for a while . In an interview on 8/26/20 at 3:54 p.m., Activity Aide JJ stated regarding Resident #105's fall on 7/2/20 at approximately 2:30 p.m., she .heard a thud but no alarms . Activity Aide JJ reported she entered Resident #105's room with the CNA and .she (Resident #105) was on the floor . Activity Aide JJ reported Resident #105 said she was .trying to get up . Activity Aide JJ stated .(Resident #105) didn't seem upset but did complain of pain in her left shoulder . In an observation on 8/27/20 at 9:50 a.m., observed Resident #105 as she sat in her wheelchair in her room. Noted a Tabs alarm was in place and clipped to the back of her shirt. In an interview on 8/27/20 at 3:14 p.m., Unit Manager G reported the Tabs alarm for Resident #105 is a Care Plan intervention, which has been in place for .months . Unit Manager G reported she would expect the CNA's to check the Care Plan prior to providing care. Unit Manager G reported the interventions in the Care Plan should be implemented by the staff. In an interview on 8/27/20 at 3:53 p.m., Director of Nursing (DON) B reported the Tabs alarm for Resident #105 was added as an intervention after a fall in January. DON B reported all staff members should check the Care Plan prior to providing care .no matter how well they know the person . Review of a Radiology Results Report for Resident #105, dated 7/2/20, revealed .X-Ray .Conclusion: Acute distal clavicle fracture, nondisplaced . Review of a Change in Condition Evaluation for Resident #105, dated 7/3/20, revealed .The change in condition, symptoms or signs I am calling about is/are .Pain (uncontrolled) .Trauma (fall related or other) .This started on .07/02/2020 .Unable to perform range of motion to left arm .Describe skin changes .discoloration .Any new skin discoloration accompanied by significant pain .Pain in left shoulder, bruising beginning to surface .Pain Evaluation .Occasional moan or groan. Low-level of speech with a negative or disapproving quality .Facial expression .Sad, frightened, frown .Body language .Tense. Distressed pacing. Fidgeting .Consolability .Distracted or reassured by voice or touch .Musculoskeletal pain .Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall .pain, no range of motion, bruising beginning .Abnormal Results .X-ray .Acute distal clavicle fracture, nondisplaced .unable to perform active or passive range of motion, with left arm, having 4/10 pain using the PAINAD scale, swelling and bruising noted to left shoulder . Review of a Physician's Note for Resident #105, dated 7/20/20, revealed .Moderately advanced [MEDICAL CONDITION] with significantly impaired short and long term memory. She has severe limitations in problem solving. Impaired judgement and poor safety awareness manifest as fall and clavicle fracture .Oriented to self only. Smiles and talkative, but lacking specific content. Unable to provide any medical history. Is notably wearing a sling on left arm (history of clavicle fracture) but no recall of any arm injury, denies hurting arm in fact, and offers no explanation for the sling . The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the fall policy was reviewed and deemed appropriate, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

Based on observation, interview, and record review the facility failed to: 1. Provide test strips in order to ensure proper sanitizer concentration; 2. Ensure the high temperature dish machine was effectively sanitizing; 3. Clean food contact surfaces to sight and touch; and 4. Properly cool potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 114 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen starting at 9:15 AM on 8/5/19 it was observed that only a few inches worth of quaternary ammonium test strips were found next to the three-compartment sink. No colorimeter chart or directions were available for reference. When asked if there was test strips anywhere else in the facility, Director of Dining Services (DDS) CC stated, We have to grab some from upstairs. Once test strips were found a brought downstairs, they were observed to be test strips for chlorine based sanitizer, and not for the quaternary ammonium product used in the kitchen. After this was pointed out, DDS CC stated, We don't have quat (strips) then. According to the 2013 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided. 2. During the initial tour of the main kitchen at 10:05 AM on 8/5/19 AM, it was observed that the rinse gauge on the dish machine was missing its cover and showing a temperature of 165°F for incoming water. Review of the Dishmachine Temperature Record, for (MONTH) and (MONTH) 2019, found 26 recorded final rinse temperatures that were below the required 180°F minimum. The logs also show that at least six of the thermo tape test strips that were used to ensure proper temperature, indicated the temperature was too low. The logs also state that corrective action is required when a low temperature is recorded. No corrective action was shown on the logs for what was done when the machine was not working properly. During a follow up tour of the kitchen at 10:50 AM on 8/6/19, it was observed that the rinse gauge was no longer showing any recorded temperature. The surveyor asked DDS CC to run a thermo-tape test strip through to ensure proper rinse temperature of the machine. The thermo-tape came out white, indicating the unit was not getting hot enough to sanitize. According to the 2013 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: .(2) For all other machines, 82C (180F). 3. During the initial tour of the kitchen at 10:28 AM on 8/5/19, it was observed that a table cloth was covering the slicer. When asked what it meant when the slicer was covered, DDS CC stated, To keep covered from debris. When asked if it meant the slicer was clean, DDS CC stated, Yes. Observation of the slicer shown white film debris on the back side of the blade as well as food debris on the catch side of the slicer (under the blade). When asked if he could see the debris, DDS CC, stated, Yes. Initial observation of the dining rooms starting at 11:03 AM on 8/5/19, observed an accumulation of white, pink, and black debris on the spouts of the following ice machines: Ritzema, Porch, Main, and West dining rooms. According to the 2013 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils shall be cleaned.(5) At any time during the operation when contamination may have occurred . 4. During the initial tour of the kitchen at 9:30 AM on 8/5/19 it was observed that the Hot Food Cooling Log, no date, stated that mashed potatoes started cooling at 9:00 AM at a temperature of 136°F. These mashed potatoes were found in the bottom of a preparation cooler, covered in saran wrap, with a small portion vented in the corner. At this time the product felt very warm to the touch. At 10:55 AM on 8/5/19, the surveyor took a temperature of the mashed potatoes and found them to be 92°F. When asked if they were going to cool to 70°F within the required 2 hours, Cook DD stated, Not going to make it, and threw them away. According to the 2013 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. According to the 2013 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3) Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on interview and record review the facility failed to verify and obtain updated Durable Power of Attorney and Advance Directives forms, for 1 of 8 residents (Resident #42), reviewed for Advance Directives, resulting in the potential for mismanagement of a resident's medical treatment or services. Findings include: Review of the Face Sheet revealed Resident #42 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's Minimum Data Set ((MDS) dated [DATE], revealed Resident #42 was cognitively impaired. Review of the Declaration of Inability to Participate in Medical Decisions form located in Resident #42's hard chart, dated [DATE], revealed . (Resident #42) .We determined that the patient is unable to participate in medical treatment decisions ., which enacted the Durable Power of Attorney. Review of the Durable Power of Attorney and Medical Directive form located in Resident #42's hard chart, dated [DATE], revealed . (Resident #42), have made, constituted and appointed and by these presents do make, constitute and appoint (Family Member FF (FM)), my true and lawful attorney, agent, or patient advocate to carry out the instruction and desires stated in this Durable Power of Attorney and Medical Directive .if unable or unwilling to serve, I appoint (FM GG) .if unable or unwilling to serve, I appoint (FM HH) . Review of the Advance Directive Summary for (Resident #42) located in Resident #42's hard chart, dated [DATE] and originally signed by Resident #42 when deemed competent, revealed .Cardiopulmonary Resuscitation (CPR) . (boxed checked) yes . (next to yes', handwritten in) .No CPR [DATE] .(signed) FM EE . FM EE was not a designee on the Durable Power of Attorney and Medical Directives form. FM EE signed the Advance Directive Summary for (Resident #42) and checked no CPR, prior to Resident #42 was deemed incompetent on the Declaration of Inability to Participate in Medical Decisions form, completed [DATE]. Review of the Emergency Medical Services DO NOT RESUSCITATE ORDER located in Resident #42's hard chart, dated [DATE], revealed Resident #42 .request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me .(signed) FM EE. FM EE was not a designee on the Durable Power of Attorney and Medical Directives form. FM EE signed the Emergency Medical Services DO NOT RESUSCITATE ORDER prior to Resident #42 was deemed incompetent on the Declaration of Inability to Participate in Medical Decisions form, completed [DATE]. In an interview on [DATE] at 11:03 AM, Social Worker X (SW) indicated the Durable Power of Attorney and Medical Directive, dated [DATE], in Resident #42's hard chart was the only Advanced Directive paper work for Resident #42 in the facility. SW X indicated FM EE, the signee, of Resident #42's Advance Directive Summary for (Resident #42) and Emergency Medical Services DO NOT RESUSCITATE ORDER was not the designated patient advocate assigned in Resident #42's Durable Power of Attorney form.

Based on interview and record review, the facility failed to have a process in place to notify the resident and/or representative of a notice of transfer for 2 residents (Resident #60 & Resident #85) of 2 residents reviewed for discharged to the hospital, resulting in the residents and/or representative not receiving complete information. Findings include: Review of a facility contract, Resident Contract . dated (MONTH) 2019, revealed, 6.c. Involuntary Transfer or Discharge: .This 30-day notice is always required unless: .An immediate transfer or discharge is required by the resident's urgent medical needs .If any of the above conditions apply, notice must be made as soon as practicable before transfer or discharge . Resident #60 Review of a Face Sheet revealed Resident #60 was an [AGE] year-old female, originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #60, with a reference date of 6/13/19, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #60 was moderately cognitively intact. During an interview on 8/05/19 at 9:44 AM Resident #60 stated, For about a week I slept a lot and just didn't feel good. I went to the hospital and come to find out I had pneumonia, an UTI, and had urosepsis. Review of Resident #60's Health Status Note dated 5/12/19 at 8:36 a.m., revealed, .ordered for her to be evaluated in the ER pending family approval. Review of Resident #60's Health Status Note dated 5/12/2019 at 9:00 a.m., revealed, .Transferred to . ER .Ambulance at 9:10 am . Resident #85 Review of a Face Sheet revealed Resident #85 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Further review revealed a Medical POA ( Power of Attorney) had been designated. Review of a Minimum Data Set (MDS) assessment for Resident #85, with a reference date of 6/26/19, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #85 was cognitively intact. Review of Resident #85's Order Entry and Health Status Notes dated 8/6/18, 9/10/18, 10/18/18, 10/31/18, 11/2/18, 12/10/18, 12/14/18, and 5/8/19, indicated the facility's physician ordered the resident to the ER (emergency room ) for evaluation and treatment and nursing staff documented the order and transfer. Resident #85's Order Entry and Health Status Notes revealed 8 missed opportunities for the facility to give the resident and/or representative a written notice of transfer/discharge. During an interview on 8/07/19 at 1:53 PM Nursing Home Administrator (NHA) A reported that a written notice of transfer/discharge has not been sent with the resident to when they go to the hospital. NHA A stated, It can be confusing for the resident when they are not in their normal state-of-mind. I do send out the bed hold form with every transfer.

Based on observation, interview and record review the facility failed to maintain professional standards for 1 of 11 residents (Resident #32) reviewed for medication administration and documentation of medications administered, resulting in untimely documentation of medication administration, the potential for the resident to receive medications that had previously been administered and the potential for medications to be administered to the wrong resident. Findings include: Review of facility policy and procedure Administering Medications dated 12/2012 revealed, Medications shall be administered in a safe and timely manner, and as prescribed .Nurses perform the triple-check 6-rights of medication administration. Right Medication, Dose, Time, Route, Documentation, and person .The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. the date and time the medication was administered . During an interview and observation on 08/06/19 at 02:10 P.M., LPN K observed on the computer to open a list of residents due for medication administration. This list was observed to include Resident #32 orders for [MEDICATION NAME], Vitamin D and Tylenol, all scheduled for 1:00 P.M. LPN K reported that she had previously administered Resident #32's medications about 1:00ish. LPN K then proceeded to sign out these medications as administered. During an observation and interview on 08/06/19 at 02:11 P.M., LPN K observed to prepare Resident #42's medications [MEDICAL CONDITION] 112mcg 1 tablet and [MEDICATION NAME] 1 capsule. LPN K then walked down the hall and knocked on Resident #32's door, when a Certified Nursing Assistant (CNA) answered reporting that the resident was toileting and that it would be a few minutes. LPN K waited a few minutes by the door, then walked back down the hall to the medication cart and opened the computer. It was observed that Resident #42's Medication Administration Record [REDACTED].these medications are for (Resident #42). During an interview on 08/07/19 at 09:40 A.M., RN/UM G reported that the expectation is that nurses sign out medications immediately after administering the medications. RN/UM G reported that the documentation should be done in real time and that it would not be acceptable for nurses to document administration of medications 1 hour and 10 minutes after having administered them. RN/UM G reported that he expects that the nurses use the resident's photo on the computer and also the photo and name above the residents bed, as identification of the right resident prior to administering medications. RN/UM reported that nurses would be allowed to move their medication cart down the hall and that this may help to avoid with confusing who the right resident is when administering medications.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent for 3 of 10 residents (Resident #565, Resident #566 and Resident #95) reviewed for medication administration, resulting in a medication error rate of 5.88 percent and the potential for an increased risk for adverse reactions. Findings include: Review of facility policy and procedure Administering Medications dated 12/2012 revealed, Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders .Nurses perform the triple-check 6-rights of medication administration. Right Medication, Dose, Time, Route, Documentation, and person .The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving each medication and beofre administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. the date and time the medication was administered . Resident #565 Review of a Face Sheet revealed Resident #565 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #566 Review of a Face Sheet revealed Resident #566 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation and interview on 08/06/19 at 02:06 P.M., LPN K observed to have Resident #566's Medication Administration Record [REDACTED]. LPN K was observed to walk down the hall approximetely 40 feet into Resident #565's room (not Resident #566) and stated, Hello (Resident #565)! LPN K observed raising the head of the bed, informing Resident #565 that she had a pill for her, scooped the pill onto a spoon and raised it up towards Resident #565's mouth, as to administer the medication. This surveyor stopped LPN K from administering the medication to Resident #565. LPN K reported that Resident #565 was the wrong resident to receive this medication. LPN K reported that the medication was intended for Resident #566. During an interview on 08/06/19 at 02:15 P.M., LPN K regarding passing medication to the wrong resident, reported that she did not usually work this hall and normally confirms that she has the right resident by utilizing the resident's photo on the computer and then the resident's photo/name above their bed. LPN K reported that she must have just gotten confused walking from the computer, down the hall to the resident's room, but that she will start double checking from now on. During an interview on 08/07/19 at 09:40 A.M., RN/UM G reported that he expects that the nurses use the resident's photo on the computer and also the photo and name above the residents bed, as identification of the right resident prior to administering medications. RN/UM reported that nurses would be allowed to move their medication cart down the hall and that this may help to avoid with confusing the right resident when administering medications. Resident #95 Review of a Face Sheet revealed Resident #95 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #95, with a reference date of 7/5/2019 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #95 was cognitively moderately impaired. During an observation on 08/06/19 at 01:42 P.M., LPN K prepared [MEDICATION NAME] 500mg 1 tablet for Resident #95. LPN K was observed to administer [MEDICATION NAME] 500mg 1 tablet to Resident #95. Review of Resident #95's (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] Tablet 650 MG Give 650 mg by mouth three times a day for mild pain was on record as a physician's orders [REDACTED]. During an interview on 8/7/19 at 02:45 P.M., RN/UM G reported that Resident #95 did not have an order for [REDACTED]. RN/UM G reported that it was a medication error to administer [MEDICATION NAME] 500mg 1 tablet to Resident #95.

Based on observation, interview and record review the facility failed to properly store medications in locked compartments for 1 of 2 medication carts (South West hall), when the medication cart was left unlocked and unattended, resulting in the potential for diversion and/or misappropriation of medication. Findings include: Review of the facility policy and procedure Administering Medications dated 12/2012 revealed, .Medications must not be left unattended and accessible to unlicensed personnel or residents/visitors .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . During an observation on 08/06/19 at 01:54 P.M., Licensed Practical Nurse (LPN) K observed at South West hall medication cart preparing medications for a resident, then observed leaving the cart unlocked, and walking approximately 50 feet down the hall, where LPN K then entered a residents room to administer medications. LPN K returned to the cart approximately 6 minutes later. It was observed that the medication cart was unlocked and LPN K opened the drawer without using the key. During an interview on 8/7/19 at 02:45 P.M., Registered Nurse/Unit Manager (RN/UM) G reported that the expectation is that the nurse would lock the medication cart when walking away from it to administer medications to a resident down the hall in their room. RN/UM G reported that the only time it would be acceptable to leave the medication cart unlocked would be if the cart was in the doorway of a resident's room and clearly visible to the nurse while administering medications to a resident.

Based on observation, interview and record review the facility failed to modify care plans and implement care plan intervention to prevent falls for 3 out of 3 residents reviewed for falls (#6, #7 and #8) from a total of 17 sampled residents resulting in multiple falls with harm from a massive hematoma and skin graft for resident #6 and multiple falls with potential for harm for residents # 7 and 8. Findings include: According to the Admission Record dated 1/16/15 Resident #6 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, which indicated moderate cognitive impairment. During an interview with Resident #6 on 2/11/15 at 2:30 PM, Resident #6 was able to give descriptive long term memory events, but gave inaccurate short term memory events. For example, Resident #6 stated he had only fallen twice, but the incident and accident reports reflected he has had 7 falls between 6/2014 and 2/2015, and 5 of the 7 falls were between 8/2014 and 11/2014. The Interdisciplinary Team notes reflected that on 8/4/14 the team reviewed Resident #6's fall on 8/3/14 at 8:03 PM when Resident #6 was getting up to transfer from wheel chair to recliner when he fell . The Fall Reporting form dated 8/3/14 at 8:03 PM reflected Resident #6 had an unwitnessed fall and had been observed on the floor. A brief narrative of the observation described "Resident (#6) laying on floor, head leaning against heater/wall, leg straight out in front of him. Resident (#6) was transferring from wheel chair to recliner when unable to get feet to move and make the turn into the recliner." Resident #6 "was educated to put call light on when wanting to transfer. - for SBA (stand by assist)." The fall report dated 8/11/14 at 10:30 PM, indicated Resident #6 was observed on the floor, and the fall was unwitnessed. The brief narrative of the observation reflected Resident #6 "is non compliant when it comes to calling for help and frequently get up by himself. Refuses to give details as to what happened. Did not hit his head. found next to toilet with w/c (wheelchair) next to him: Shoulders ribs hips with no s/s (signs or symptoms) of problem - small abrasion on right knee - left knee has a large Hematoma, marked with sharpie & ice applied." The summary of the fall investigation on 8/11/14 reflected Resident #6 "sustained an abrasion to his right leg and a hematoma to his left leg. He was assessed by licensed nurses immediately following the incident and was sent to the hospital several hours later after the hematoma grew in size and was bleeding." Under "Investigation of Circumstances Contributing to Incident:" the content reflected Resident #6's "lower extremities have been noted to be edematous and cyanotic as well as having dry and fragile skin since admission. The resident (#6) also is on Coumadin and [DIAGNOSES REDACTED]. Cognitively, the resident does have a [DIAGNOSES REDACTED]. This resident (#6) has been educated numerous times regarding the need to call for assistance." Under conclusion, the resident (#6) had been educated on calling for assistance and acknowledged it was for his safety." Resident #6's "Cognitive and Mood Assessments" dated 6/2/14 BIMS score was a 12 out of a possible 15, on 8/26/14 Resident #6's BIMS score was 9 out of a possible 15. The "Resident Education Record" on Resident #6 dated 8/26/14 reflected skin grafting was done and he had a fall with injury and hospitalization on [DATE]. This "Resident Education Record" indicated "I spoke with (Resident #6) at length today about a serious fall that occurred in his bathroom on the evening of August 11. (Resident #6) injured himself when attempting a transfer from the toilet to his wheel chair in his bathroom. The injury was severe enough to warrant hospitalization and skin grafting on left upper leg. ...We feel very bad when an injury like this happens ... I asked him to try to remember how serious this event was the time he was tempted to transfer himself... He (Resident #6) said he was going to try hard to remember that!" physician progress notes [REDACTED].#6 "was seen for re-admission after being sent to the hospital on 8/12 with left leg injury. Apparently he had a massive hematoma and (another doctor) was quite concerned about the possibility of [DIAGNOSES REDACTED]." The "Fall Reporting Form" dated 8/31/14 7:12 AM reflected Resident #6 was observed on the floor having an unwitnessed fall. The brief narrative of the observation of the incident reflected "Resident (#6) noted leaning against wall, feet out in front of him. Resident stated he was transferring self from recliner to wheelchair, brakes were on wheelchair. Resident (#6) stated "my left knee gave out on me." physician progress notes [REDACTED].#6 "was seen for multiple reasons. First, he had a fall on 8/31 when he was found sitting on the floor at 7:12 P.M. after attempting to self transfer. There were no sings of injury. He states that his knees seemed to give out on him. It may well be that his recent hospitalization for left lower leg hematoma requiring skin graft with a harvest site from the left thigh contributed to some deconditioning and hence this fall. I did, of course, remind him that he needs help with any and all transfers and mobility at this time, particularly after his recent injury and procedure." The physician progress notes [REDACTED].#6's) fall relates to side effects of medications or failure of his medical regimen. I believe the fall relates to his dementia with altered safety awareness and motor planning." Although Doctor "E" related the multiple falls were related to dementia and altered safety awareness, the facility still continued to educate Resident #6 with reminders to use his call light and wait for the nurse aides to assist him with transfers. For example, the "Resident Education Record" dated 12/4/14 reflected the facility instructed him regarding a fall that took place on 11/21/14. The discussion with Resident #6 reflected "Staff talks to him often about being patient and waiting for assistance, but the result is that he becomes depressed about it. He does not like to think that he can no longer do for himself. When I spoke to him about waiting for assistance, he comment was 'Yeah, I'll wait for assistance. I want assistance right out of the door.' He did have his bathroom call light on, but said he was unable to wait for help to come and he was going to help himself. When his cna (certified nurse aide) arrived he as halfway between his wheelchair and the toilet seat but unable to complete the transfer... I reminded him that we only bring it up because we do not want him to get hurt, and I reminded him of the serious fall he had in August that resulted in hospitalization I will speak about this again with him again in a couple weeks." Although Resident #6 repeatedly gets up unassisted, they continue to educate him as if his BIMS was 15 out of 15 (cognitively intact) and as if he had no dementia. According to Resident #6's "Cognition and Mood Assessments" dated 10-26-14 Resident 6's BIMS was 10 out of a possible 15, reflecting moderate cognitive impairment. The Facility's added interventions and continued education instructions to Resident #6 resulted in repeated self transfers causing a "massive hematoma" which required surgical debridement, and "may" have caused "some deconditioning." The safety assessment tool dated 1/27/15 reflected resident #6 had Dementia, poor decision making, gait imbalance, uses assistive devices, had a history of [REDACTED]. On this same form, under continued assessment dated [DATE], it reflected physical therapy "just changed his care plan on 1/26/15" from an assistance of one "to assistance of 2 or 3 in large bathroom for toilet transfers and using a hoyer for ... transfers..." Thus, Resident #6 has had a decline in transfer status. ( ) Resident #8 Review of Resident #8's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #8's Minimum Data Set (MDS) an assessment tool, dated 11/4/15 revealed her cognitive skills for daily decision making score was 2 (Moderately impaired), which means she required cues/supervision and had poor decision making skills. Review of the Activities of Daily Living assistance assessment revealed Resident #8 required supervision and set up with transfers and walking in her room/corridor. Review of Resident #8's "Fall/Near Fall Reporting Forms" from 5/10/14 through 1/30/15 revealed Resident #8 had 19 falls (fall dates 5/10/14, 6/22/14, 6/26/15, 7/6/14, 7/18/14, 7/19/14, 9/2/14, 9/5/14,9/11/14, 9/27/14, 10/13/14,10/25/14, 12/7/14, 12/25/14, 1/3/15,1/12/15, 1/21/15, 1/28/15, 1/30/15). Review of the "Fall/Near Fall Reporting Form" dated 1/21/15 revealed Resident #8 fell on [DATE] at 7:05 PM, had an unwitnessed fall and fell when going to sit down on at chair in the dining room. The corrective action was Geri hips (padded underwear to help prevent fracture when the person falls). No root cause of fall was documented. Review of the "Fall/Near Fall Reporting Form" dated 1/28/15 revealed Resident #8 fell on [DATE] at 1:00 PM, had an unwitnessed fall and fell when trying to sit down. The corrective action was to continue to assist as Resident #8 allows. No root cause was documented. Review of the "Fall/Near Fall Reporting Form" dated 1/30/15 at 3:10 PM, revealed Resident #8 fell on [DATE], had a witnessed fall and fell when she bumped into the wall and rolled onto the floor and sustained a skin tear on her right leg that measured 5 cm x 3.5 cm. The corrective action was one on one care and observe closely/assist as needed. Review of Resident #8's care plan dated 5/7/14 revealed the following interventions for fall precautions: gripper socks at night, bed pad alarm, red seat pad in bedside chair, gait belt on at all times when up as allows, assist resident to sit as able (12/7/14), encourage to wear glasses (12/16/14), keep walk way clear (1/12/15), therapy consult for suggestions regarding depth perception (1/13/15), Geri hips as allowed, encourage rest periods when pacing. (one on one and close observation were not listed as interventions as documented after the fall on 1/30/14). There was no intervention that indicated Resident #8 required assistance to sit. During an interview with the Unit Manager, Registered Nurse (RN) "A" and Acting Director of Nursing (DON) "B" on 2/9/15 at 3:40 PM this Surveyor asked "A" and "B" what was the root cause of Resident #8's falls on 1/21/15, !28/15 and 1/30/15 and they said that the root cause for all the falls was Resident #8 lacks depth perception. This Surveyor asked what were the fall interventions placed for Resident #8 for the three falls that would assist Resident #8 with her depth perception problem to keep her safe. "A" and "B" were unable to locate any care plan interventions related to assisting Resident #8 with safety related to her depth perception problem. This Surveyor asked what was different about the days resident #8 fell , because the Resident #8 was not falling every day and "A" and "B" Resident #8 had new glasses and it was determined that they could not fix the depth perception problem. "A" and "B" said staff did not assist Resident #8 when she was attempting to sit on the days she fell . "A" and "B" said Resident #8 can not safely sit unless staff help her. Resident #8 was observed in the locked unit dining room on 2/9/15 at 4:30 PM walking and sitting in a dinning room chair with assistance. Resident #8 required verbal cues and physical assistance to back up to the chair and sit. Review of the facility, "Falls Management Committee/Program", dated revised December 2007, revealed under Inital Assessment, "Assess root cause(s) and formulated resident specific interventions to address risk factors/root cause. (Resident #8 did not have documented root causes for her fall or specific interventions related to a root cause). ( ) Resident #7 Resident #7 was a [AGE] year old female admitted to the facility 6/2/10, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 which indicated the Resident was severely cognitively impaired. In an interview conducted 2/10/15, at 3:12 PM, Resident #7 reported she did not know how long she lived at the facility. Resident #7 reported she had not fallen since she had been at the facility. The Resident reported when she needs help she calls her daughter. Review of the Initial Psychological Evaluation completed 5/14/14, for Resident #7 revealed the Resident was oriented "x 1" (to self), with thought processes that were of "confusion" and were "illogical". The evaluation report indicated Resident #7's judgement was "poor", her cognition was "impaired", and memory deficits included information that was, "Immediate", "Recent", and "Remote". Review of the Resident Care Plan (undated) for Resident #7 revealed "Cognition" to be A&O (alert and oriented) " x 1 -person only" and her "Behavior/Mood: can be compulsive", The Care Plan revealed Resident #7 needed her glasses for reading and "Prefers light off in room". The plan revealed "Fall Precautions" to include "repeated reminders to use walker", and a "sign on walker as a reminder to ask for help when toileting". Review of the Fall/Near Fall Reporting Forms for Resident #7 revealed she fell on [DATE] at 6:30 AM, 11/9/14 at 4:30 AM, 12/14/14 at 6:10 AM, 1/13/15 10:10 AM, and 1/21/15 at 8:59 AM. Review of the reports revealed the interventions recommended by the Inter Disciplinary Team reviewing the falls were similar, and essentially unchanged, to the interventions initiated by the nurse immediately post-fall. Review of the interventions included, reminding the Resident to use her walker, adjusting and adding alarms, and placing a sign on the walker for the Resident to read. The documents did not reveal further investigation of each fall was conducted by the Team reviewing the falls. The documents did not reveal an attempt to determine the root cause following each fall. The facility "Falls Management Committee/Program dated 2001, and revised 12/2007 was reviewed. The document indicated the Falls Management Committee (FMC), "conducts further investigation as needed". The document revealed the FMC will, "assess root cause(s) and formulates resident specific interventions to address risk factors/root cause". ( )

This citation pertains to intake number: MI 760 Based on observation, interview, and record review, the facility failed to provide supervision and assistance with hot liquids in 1 of 7 residents (Resident #101) reviewed for safety with hot liquids, from a total sample of 7 residents, resulting in an Immediate Jeopardy when Resident #101, who was identified as being unsafe for hot liquids, spilled hot soup onto his lap that was 180 degrees Fahrenheit (measured by dietary staff) during dinner on 12/8/12, causing first-degree burns to the right inner thigh and second-degree burns the left inner thigh. The deficient practice places 48 residents, who require lids with hot beverages, at risk for serious harm and/or injury. Findings include: Review of Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had severe cognitive impairment. Review of the "Joint Range of Motion Measurements and Beverage Screen", dated 5/23/12, revealed Resident #101 was not "safe to independently manage hot liquids, and needs assist with beverages." Review of the "Resident Care Plan" (Nurse Aide Care Guide), dated 10/3/12, revealed Resident #101 needed assistance with eating but did not include information or documentation to indicate that Resident #101 was unsafe to independently manage hot liquids. Review of Resident #101's, "Potential for physical injury care plan", dated 5/11/11 and updated 5/22/12, revealed no interventions for handling hot liquids were in place prior to 12/8/12. In an interview, on 12/17/12 at 2:30 p.m., Registered Dietitian (RD) #7 was questioned how staff would know if a resident was unsafe to independently handle hot liquids. RD #7 stated that assistance would be listed on the Resident Care Plan (Nurse Aide Care Guide). In a second interview on 12/17/12 at 3:00 p.m., RD #7 stated she did not change anything on Resident #101's "Resident Care Plan" after the beverage screens on 11/15/11 and 5/23/12. Review of the nursing notes, dated 12/8/12 at 5:30 p.m., revealed Resident #101 "pulled all his food in his lap." The note indicated that at 6:30 p.m., Resident #101 was assessed by Registered Nurse (RN) #14, and his inner thighs were red/pink. The note indicated at 11:20 p.m., RN #17 noted "bilateral upper inner thighs red and sore with 2 blisters (intact) seen on left inner upper thigh. Larger one measures approximately 1.5 cm x 1 cm and smaller one measures approximately 0.5 cm diameter ..." RN #17 notified the Nurse Practitioner at 11:20 p.m. Review of the "Temperature Log and Checklist," dated 12/8 (no year), provided by the RD #7 revealed the temperature of the soup at dinner on 12/8/12 was 180 degrees Fahrenheit. Review of the posted meal serving times, revealed dinner is served between 4:45 p.m. and 5:00 p.m. In an interview, on 12/17/12 at 2:35 p.m., Certified Nurse Aide (CNA) #12 stated she was in the west dining room on 12/8/12, during dinner, when Resident #101 spilled his soup on his lap. CNA #12 stated, "When I found him, I pulled him away from the table. He had food and soup on his pants. The bowl was on the floor." CNA #12 stated it had been 15 minutes "or longer" since Resident #101 had received his food at the table. CNA #12 stated there was not a staff member at Resident #101's table when the spill occurred. When asked how the CNA's know which table to sit at and assist residents, CNA #12 stated "we sit where the assisted ones (residents) need help" . In an interview, on 12/17/12 at 2:45 p.m., CNA #13 stated she was in the west dining room on 12/8/12, during dinner, assisting residents to eat. CNA #13 stated she was feeding a resident across the table from Resident #101 and then moved to a different table to assist two other residents. CNA #13 stated, "I looked over and thought he (Resident #101) ate well". CNA #13 stated, "Soup isn't always served with a lid on it." In a telephone interview on 12/17/12 at 4:10 p.m., CNA #16 reported that, on 12/8/12, she was in the dining room feeding and supervising residents when another CNA (#12) pulled Resident #101 away from the table and noticed Resident #101 had a mess in his lap. CNA #16 reported that she took Resident #101 back to his room, took his pants off, and noticed wet liquid and food particles in his lap. CNA #16 reported, "I didn't even think it was a burn, I laid him down, removed his pants and cleaned him up. He had red, irritated thighs; I thought the redness was from wetness. I cleaned him up, put Aloe Vesta lotion on his inner thighs and told (Registered Nurse/RN #14)." When questioned about how she would know if a resident was unsafe to handle hot liquids, CNA # 16 reported, "I wouldn't know, I don't know, I look at the resident care plan in the closet door, and it only says if someone needs assist in feeding or they are independent." In an interview on 12/17/12 at 3:45 p.m., RN #14 stated, "The aide (CNA #16) told me he (Resident #101) pulled all his food items on his lap during dinner." When asked if she suspected Resident #101 was burned upon notification from CNA #16, RN #14 stated, "Well, that's what I deducted since they told me his food was in his lap." RN #14 stated any resident that needs assistance eating or has cognitive issues is at risk for burns from hot liquids. RN #14 stated, "General policy is you don't leave anything excessively hot in front of anyone." Review of the nursing notes, dated 12/10/12 at 11:45 a.m., revealed a drawing of Resident #101's inner thighs. The note indicated Resident #101's right inner thigh had one intact blister measuring 3 cm x 1 cm with surrounding "patchy red areas" that measured 11 cm x 4 cm. The left inner thigh had three intact blisters measuring 0.5 cm x 1 cm, 5 cm x 3 cm, 2 cm x 1.5 cm, and had surrounding "patchy red areas" measuring 11 cm x 8 cm. Review of the Nurse Practitioner Progress Notes, dated 12/10/12, revealed Resident #101's inner thighs were assessed and Resident #101 had a "pink area not blanchable...some small little blisters developed..." Review of the physician progress notes [REDACTED]. His (Resident #101) right inner thigh shows some patchy [DIAGNOSES REDACTED] (redness of the skin) consistent with first-degree burns. Over the left inner thigh there are some patchy areas of [DIAGNOSES REDACTED] and three areas where previous blisters have opened showing intact dermis beneath. These are areas of second-degree burn." During an observation, on 12/17/12 at 11:30 a.m., Dietary Aide #8 obtained the following food temperatures in the west dining room: turkey was 167 degrees, mashed potatoes were 176 degrees, and coffee was 148 degrees. In an interview, on 12/17/12 at 11:30 a.m., Dietary Aide #8 stated she had "never had anything too hot" and the manager collects the temperature logs at the end of the month for review. During an observation, on 12/17/12 at 11:45 a.m., Dietary Aide #9 obtained the following food temperatures in the southwest dining room: gravy was 164 degrees and coffee was 144.7 degrees. The hot cart, which stored the gravy, was observed with a temperature setting of 173 degrees Fahrenheit. In an interview, on 12/17/12 at 11:45 a.m., Dietary Aide #9 stated the supervisor "comes up every month" and checks the temperature logs. When asked what he would do if food was too hot, Dietary Aide #9 stated, "I would turn the heating element off...and not serve right away". Review of the "Meal Temperature Record" policy and procedure, dated 5/95 and updated 3/11, stated "If supervisor is NOT the person to take and record temperatures they must review the recorded temperatures prior to meal service to ensure temperatures meet standards". During an observation on 12/17/12 at 4:00 p.m. with Licensed Practical Nurse (LPN) #15, Resident #101 had dressings, dated 12/17/12, on his left and right inner thighs. Resident #101 moaned when the dressings were removed by LPN #15. The right inner thigh was observed with a circular patch of redness approximately 2 cm x 2 cm. The left inner thigh was observed with an open blister and surrounding redness of approximately 8 cm x 4 cm. On 12/19/12, Administrator #1 was notified of an Immediate Jeopardy that began on 12/8/12 and was identified on 12/17/12 as a result of the facility's failure to provide supervision and assistance with hot liquids for Resident #101, who was identified as being unsafe for hot liquids, spilled hot soup onto his lap that was 180 degrees Fahrenheit during dinner on 12/8/12, causing first-degree burns to the right inner thigh and second-degree burns the left inner thigh. On 12/20/12 the surveyors confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. Resident #101 was reassessed on 12/10/12 for his ability to safely handle hot liquids. Based on that assessment, Resident #101 continues to require assistance and supervision with hot liquids, which is being provided by staff. Interventions regarding hot liquids were placed on Resident #101 care plan and meal ticket. 2. Beginning on 12/19/12, 48 of 139 residents have been reassessed to safely handle hot liquids. 48 residents have been identified as requiring interventions and or some level of assistance or supervision with meals. These hot liquid interventions and the need for assistance or supervision have been indicated on each residents care plans and meal tickets. Residents will continue to be assessed until all residents have been completed. 3. As of 12/8/12, the therapy department continued to assess all new residents upon admission within 24 hours for their ability to safely handle hot liquids. The therapy department communicated the results of those screening to the unit managers and dietary department who placed the information on the residents care plans and meal tickets. 4. The policy for hot liquids was reviewed and updated on 12/10/12. 5. Beginning on 12/10/12, all dietary and nursing staff were being in-serviced face to face on where to locate the interventions and level of assistance that is required for each resident to handle hot liquids as well as the need to provide adequate supervision and assistance as specified on the residents care plans and meal tickets. As of 12/19/12, 12 of 42 dietary staff, 45 out of 55 RN's and LPN's, and 102 out of 124 CNA's have been in-serviced. All staff will be in-serviced before working with residents. 6. The staff development coordinator began auditing 12/11/12 on a weekly basis, to ensure that interventions identified on hot liquid assessments have been placed on care plans and meal tickets, that staff are aware of where to locate information of if a resident requires assistance or interventions with hot liquids, and that staff are providing adequate supervision and assistance as specified on the residents care plans. Although the Immediate Jeopardy was removed on 12/11/12, the facility remained out of compliance at the scope of isolated and a severity of actual harm that is not Immediate Jeopardy due to all of the staff had not yet been in-serviced, all care plans and meal tickets had not been completely updated with interventions, and sustained compliance had not been verified by the state agency. ( , )

This citation pertains to intake number: MI 760 Based on interview and record review, the facility failed to ensure care plan interventions were in place for assistance with hot liquids in 1 of 7 residents (Resident #101) reviewed for safety with hot liquids, from a total sample of 7 residents, resulting in Resident #101, who was identified as being unsafe for hot liquids and had no care planned interventions in place for hot liquids, spilled hot soup onto his lap that was 180 degrees Fahrenheit causing first-[MEDICAL CONDITION] the right inner thigh and second-[MEDICAL CONDITION] left inner thigh. Findings include: Review of Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had severe cognitive impairment. Review of the "Joint Range of Motion Measurements and Beverage Screen", dated 11/15/11, revealed Resident #101 had a change in the beverage screen and needed assistance with beverages. Review of the "Joint Range of Motion Measurements and Beverage Screen", dated 5/23/12, revealed Resident #101 was not "safe to independently manage hot liquids, and needs assist with beverages." In an interview, on 12/17/12 at 2:20 p.m., Occupational Therapist (OT) #11 reported that, after the OT screened a resident for hot liquids, the assessment tool was given to the nurse manager and to the Dietitian who were to document it in the resident's care plan. Review of the "Resident Care Plan" (Nurse Aide Care Guide), dated 10/3/12, revealed Resident #101 needed assistance with eating but did not include information or documentation to indicate that Resident #101 was unsafe to independently manage hot liquids. Review of Resident #101's, "Potential for physical injury care plan" dated 5/11/11 and updated 5/22/12 revealed no interventions for handling hot liquids were in place prior to 12/8/12. Review of Resident #101's, "Potential alteration in nutrition and hydration" dated 5/16/11 revealed no interventions for handling hot liquids were in place prior to 12/8/12. In an interview, on 12/17/12 at 2:30 p.m., Registered Dietitian (RD) #7 was questioned how staff would know if a resident was unsafe to independently handle hot liquids. RD #7 stated that assistance would be listed on the Resident Care Plan (Nurse Aide Care Guide). In a second interview on 12/17/12 at 3:00 p.m., RD #7 stated she did not change anything on Resident #101's "Resident Care Plan" after the beverage screens on 11/15/11 and 5/23/12. Review of the nursing notes, dated 12/8/12 at 5:30 p.m., revealed Resident #101 "pulled all his food in his lap." The note indicated that at 6:30 p.m., Resident #101 was assessed by Registered Nurse (RN) #14, and his inner thighs were red/pink. The note indicated at 11:20 p.m., RN #17 noted "bilateral upper inner thighs red and sore with 2 blisters (intact) seen on left inner upper thigh. Larger one measures approximately 1.5 cm x 1 cm and smaller one measures approximately 0.5 cm diameter ..." RN #17 notified the Nurse Practitioner at 11:20 p.m. In an interview, on 12/17/12 at 2:45 p.m., CNA #13 stated she was in the west dining room on 12/8/12, during dinner, assisting residents to eat. CNA #13 stated she was feeding a resident across the table from Resident #101 and then moved to a different table to assist two other residents. CNA #13 stated, "I looked over and thought he (Resident #101) ate well". CNA #13 stated, "Soup isn't always served with a lid on it." CNA #13 stated she was not sure how to find out if a resident needs lids with hot liquids or if they are safe to independently manage hot liquids. In a telephone interview on 12/17/12 at 4:10 p.m., CNA #16 reported when questioned about how she would know if a resident was unsafe to handle hot liquids, CNA # 16 reported, "I wouldn't know, I don't know. I look at the resident care plan in the closet door, and it only says if someone needs assist in feeding or they are independent." In an interview on 12/17/12 at 3:45 p.m., RN #14 stated the risk for hot [MEDICAL CONDITION] be on the resident care plans in the closets. RN #14 stated, "General policy is you don't leave anything excessively hot in front of anyone." RN #14 stated, "Anyone can update a care plan." In a telephone interview on 12/18/12 at 11:05 a.m., RN #17 stated if something hot is on the tray and the resident is having difficulty feeding themselves or is shaky, they are supposed to have supervision or assistance. When queried about the facility's policy regarding hot liquid assessments, RN #17 reported "the facility has the dietician and therapy work together". RN #17 reported, prior to (Resident #101's) hot liquid spill, there was not anything specific about hot liquids on the dietary tray cards, nor on the care plan, nor on the Resident Care Plan (Nurse Aide care guide). ( )

This citation pertains to intake number: MI 760 Based on observation, interview, and record review the facility failed to provide necessary care and services to meet the highest practicable physical well-being (adequate care after a burn) in 1 of 7 sampled residents (Resident #101) reviewed for safety with hot liquids, from a total of 7 sampled residents, resulting in delayed treatment and inappropriate care after Resident #101 spilled hot soup on his lap and sustained a first degree burn to right inner thigh and second [MEDICAL CONDITION] left inner thigh. Findings include: Record review of Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had severe cognitive impairment. Review of the "Joint Range of Motion Measurements and Beverage Screen," dated 5/23/12, revealed Resident #101 was not "safe to independently manage hot liquids, and needs assist with beverages." Review of the nursing notes, dated 12/8/12 at 5:30 p.m., revealed Resident #101 "pulled all his food in his lap." In an interview, on 12/17/12 at 2:35 p.m., Certified Nurse Aide (CNA) #12 stated she was in the west dining room on 12/8/12 during dinner, when Resident #101 spilled his soup on his lap. CNA #12 stated, "When I found him, I pulled him away from the table. He had food and soup on his pants. The bowl was on the floor." CNA #12 stated it had been 15 minutes "or longer" since Resident #101 had received his food at the table. CNA #12 stated there was not a staff member at Resident #101's table when the spill occurred. In a telephone interview on 12/17/12 at 4:10 p.m., CNA #16 reported that, on 12/8/12, she was in the dining room feeding and supervising residents when another CNA (#12) pulled Resident #101 away from the table and noticed Resident #101 had a mess in his lap. CNA #16 reported that she took Resident #101 back to his room, took his pants off, and noticed wet liquid and food particles in his lap. CNA #16 reported, "I didn't even think it was a burn, I laid him down, removed his pants and cleaned him up. He had red, irritated thighs; I thought the redness was from wetness. I cleaned him up, put [MEDICATION NAME] lotion on his thighs and told (Registered Nurse/RN #14)." CNA #16 reported that around 9:30 p.m., she was performing bed checks and she saw two blisters on Resident #101's thighs. CNA #16 stated, "I spoke with (RN #14) and I informed her of what I saw. (RN #14) told me to apply an ice pack; I did and then I went home at the end of my shift." Review of the nursing notes, dated 12/8/12 at 6:30 p.m., revealed Resident #101 was assessed by RN #14, and his inner thighs were red/pink. In an interview on 12/17/12 at 3:45 p.m., RN #14 stated, "The aide (CNA #16) told me he (Resident #101) pulled all his food items on his lap during dinner." RN #14 stated, "I didn't get right in there (Resident #101's room). We were short a nurse on another hall and I had to pass meds." RN #14 stated she assessed Resident #101 between 6:30 p.m. and 7:00 p.m. on 12/8/12 and found that Resident #101 had approximately 5 - 7 cm of redness on both his inner thighs and did not have blisters at that time. RN #14 stated, "I told her (CNA#16) to apply [MEDICATION NAME] and ice on his (Resident #101's) thighs since there were no blisters." RN #14 stated she later (no defined time) looked at Resident #101's legs and told her supervisor (RN #17), who assessed, measured and notified the physician. When asked if she suspected Resident #101 was burned upon notification from CNA #16, RN #14 stated, "Well that's what I deducted since they told me his food was in his lap." According to the Burn Institute, first aid [MEDICAL CONDITION] the following steps, "Stop the burning process, remove the source of heat...remove all burned clothing...pour cool water over burned area, keep pouring the cool water for at least 3-5 minutes, never put ice or cold water on a burn as it lowers the body temperature and can make the burn worse...do not apply ointments, creams, or salves to wound...cover burn with a soft, clean, dry dressing, bandage or sheet. Seek medical attention as soon as possible." (www.burninstitue.org/fbp/factsheets/firstaid.html) In a telephone interview on 12/18/12 at 11:05 a.m., RN #17 stated, "At approximately 10:40 p.m. on 12/8/12, (RN #14) told her about (Resident #101's) burn. I went in and saw he had a couple blisters on his thighs, they were reddened. I called the nurse practitioner and got orders." Review of the nursing notes, dated 12/8/12 at 11:20 p.m., RN #17 noted "bilateral upper inner thighs red and sore with 2 blisters (intact) seen on left inner upper thigh. Larger one measures approximately 1.5 cm x 1 cm and smaller one measures approximately 0.5 cm diameter ..." RN #17 documented that she notified the Nurse Practitioner of Resident #101's burn at 11:20 p.m. (50 minutes after being notified of the burn) and received orders for [MEDICATION NAME] cream and gauze dressing for Resident #101's thighs. Review of the nursing notes, dated 12/10/12 at 11:45 a.m., revealed a drawing of Resident #101's inner thighs. The note indicated Resident #101's right inner thigh had one intact blister measuring 3 cm x 1 cm with surrounding "patchy red areas" that measured 11 cm x 4 cm. The left inner thigh had three intact blisters measuring 0.5 cm x 1 cm, 5 cm x 3 cm, 2 cm x 1.5 cm, and had surrounding "patchy red areas" measuring 11 cm x 8 cm. Review of the Nurse Practitioner Progress Notes, dated 12/10/12, revealed Resident #101's inner thighs were assessed and Resident #101 had a "pink area not blanchable...some small little blisters developed... " Review of the physician progress notes [REDACTED].#101) right inner thigh shows some patchy [DIAGNOSES REDACTED] (redness of the skin) consistent with 1st degree burns. Over the left inner thigh there are some patchy areas of [DIAGNOSES REDACTED] and 3 areas where previous blisters have opened showing intact dermis beneath. These are areas of 2nd degree burn." An observation on 12/17/12 at 4:00 p.m. with Licensed Practical Nurse (LPN) #15 revealed Resident #101 had dressings on his left and right inner thighs dated 12/17/12. Resident #101 moaned when the dressings were removed by LPN #15. The right inner thigh was observed with a circular patch of redness approximately 2 cm x 2 cm and no blisters present. The left inner thigh was observed to have an open blister that was approximately 2 cm x 2 cm with surrounding redness of approximately 8 cm x 4 cm. In an interview on 12/20/12 at 9:15 am, Nursing Home Administrator #1 reported that prior to 12/8/12 there was no policy or procedure for care needed for burns. ( , )